SLIGHT  AILMENTS 

NEW  ENLARGED  EDITION. 

BE  ALE 


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On    slight    ailrronts . 


University  of  California 


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ON 


SLIGHT  AILMENTS: 


THEIR 


NATURE  AND  TREATMENT. 


OTHER  WORKS 

BY 

LIONEL  S.  BEALE,  M.D.,  F.R.S. 


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ON 


SLIGHT  AILMENTS: 

n 


THEIR 


NATURE   AND  TREATMENT. 


BY 

LIONEL  S.  BEALE,  M.B.,  F.R.S., 

FELLOW   OP   THE  BOYAL    COLLEGE   OF   PHYSICIANS;    PROFESSOR  OF  THE   PRINCIPLES   AND   PRACTICE   OF 

MEDICINE   IN    KING'S   COLLEGE,    LONDON,    AND   PHYSICIAN  TO   KING'S   COLLEGE    HOSPITAL; 

LATELY   PROFESSOR    OF    PATHOLOGICAL   ANATOMY,  AND   FORMERLY    PROFESSOR   OF 

PHYSIOLOGY  AND  OF  GENERAL  AND  MORBID  ANATOMY  IN  KING'S  COLLEGE. 


SECOND    EDITION, 


ENLARGED  AND  ILLUSTRATED. 


PHILADELPHIA: 

P.   BLAKISTON,   SON    &   CO., 

No.    1012    WALNUT   STREET. 

1885. 


1    W.J|    V .... 


PUBLISHERS'  NOTICE.— This  new  re- 
vised edition  of  Dr.  Beales  ''Slight  Ailments  "  is 
published  simultaneously  with  the  London  Edition, 
by  special  arrangement  between  Dr.  Beale  and 
P.  Blakiston,  Son  and  Co.  It  is,  therefore,  the  only 
authorized  edition,  and  contains  all  the  Additions,, 
Illustrations,  and  a  complete  Index,  as  in  the  Lon- 
don Edition* 


so 

33k 


TABLE  OF  CONTENTS. 


Introductory. 

Slight  ailments  and  civilization;  Interest  in  the  patient ;  Attention  and  kindness; 
Tact  and  treatment;  Quackery  and  tact;  Humbug;  Vulgarity;.  Decillionths  of 
grains ;  Credulity  and  imposition ;  Imposture  and  nonsense ;  Principles  of  con- 
duct; Studying  slight  ailments;  Self-supporting  dispensaries;  Remedies  in- slight 
ailments;  Knowledge  derived  from  microscopical  observation ;  Intermolecular 
circulation 17-41 

Of  the  Tongue  in  Health  and  in  Slight  Ailments. 

Characters  in  health;  The  dorsum  of  the  tongue;  Funglform  and  filiform 
papillae  and  their  covering;  Epithelial  cells;  Fungi  and  low  organisms  in  the 
mouth;  Bacteria  ;  Tongue  in  various  derangements;  Importance  of  secretion ; 
Dry  and  moist  states  of  the  tongue;  Exciting  the  flow  of  saliva;  White  moist 
furred  tongue ;  Bright  red  tongue ;  Dry  brown  tongue;  Haemorrhage  ;  Cracks 
and  fissures ;  Changes  in  the  mucous  membrane  of  mouth  and  fauces ;  Inhalers, 
bronchitis  kettle;  Of  the  use  of  spray;  Metallic  and  other  tastes  in  the  mouth; 
Aphthae,  thrush,  sores,  and  ulcers  in  the  mouth  ;  Treatment  of  aphthae ;  Offensive 
breath;  Use  of  purgatives;  Use  of  mercury 4I~75 

Appetite — Nausea — Thirst — Hunger. 

Impaired  appetite;  Loss  of  appetite  ;  Voracious  appetite,  bulimia;  Nausea; 
Treatment  of  nausea  ;  Objections  to  alcohol ;  Thirst 75~^4 

Indigestion:  Its  Nature  and  Treatment. 

Indigestion,  dyspepsia  ;  Nerve-fibres  of  intestinal  canal ;  Nerve-ganglia  and 
plexuses;  Gastrodynia-;  Heartburn,  pyrosis,  or  vvalerbrash  ;  Flatulence,  wind  in 
the  stomach  ;  Treatment  of  ordinary  forms  of  indigestion  ;  Of  condiments  ;  In- 
fluence of  cold  ;  Indigestion  from  failing  glands,  as  in  old  age ;  Of  pepsine  and 
its  uses  Method  of  preparing  pepsine 84-111 

Of  Constipation. 

Importance  of  regular  action  of  bowels ;  Impaction  of  faecal  matter  in  large 
intestine  ;  Influence  of  the  reabsorption  of  fluid  in  causing  constipation  ;  Haemor- 
rhoids or  piles 111-122 

Treatment  of  Constipation. 

Of  the  action  of  enemata ;  Hygienic  and  dietetic  treatment  of  constipation; 
Exercise,  cold-bath,  rubbing,  moist  applications,  etc.;  Diet;  Of  taking  fluid; 
Smoking  tobacco  ;  Of  purgatives  in' constipation  ;  Drastic  and  hydragogue  purga- 
tives ;  Saline  purgatives;  Friedrichshall  and  other  waters 123-144 

2  xiii 


Xiv  CONTENTS. 

Diarrhoea. 

Ordinary  diarrhoea;    Nature   and   causes   of  diarrhoea;    Treatment  of  diar-     . 
rhoea 144-152 

Intestinal  Worms. 

Threadworms;    Large  round  worm ;  Remedies  to  be  used 152-154 

Vertigo — Giddiness. 

Vertigo,  swimming  in  the  head;  Causes;  Aural  vertigo,  treatment,  etc*...   154-157 

Biliousness— Sick  Headache. 

Biliousness;  Derangement  of  the  liver  ;  Treatment  of  biliousness;  Action  of 
east  wind;  Jaundice*  Yellow  atrophy;  Sick  headache  ;  Treatment  of  sick  head- 
ache ;  Treatment  of  sick  headache  during  the  attack;  Starving;  Treatment  of 
sick  headache  in  the  intervals  between  the  attacks;  Of  the  management  of  sick 
headache  when  the  patient  continues  at  work ;  Drowsiness ;  Wakefulness  and 
restlessness 157-186 

Neuralgia — Rheumatism. 

Nervousness;  Neuralgia;  Treatment  of  neuralgia;  Rheumatic  pains  ;  Treat- 
ment of  rheumatism  ;  Free  sweating;  Diet  in  rheumatism;  Warm  clothing.  187-202 

On  the  Feverish  and  Inflammatory  State. 

Of  catching  cold  ;  Preliminary  changes  and  attendant  phenomena ;  Rise  in  the 
body-heat  in  all  fevers  and  inflammations  ;  Is  there  increased  oxidation  in  fever 
and  inflammation?  Method  of  ascertaining  the  temperature  of  the  body;  Fever, 
rigors,  hot  stage,  sweating  stage  ;  Of  free  secretion  leading  to  recovery  ;  Princi- 
ples of  treatnlent  of  a  cold;  Management  of  affections  beginning  like  a  cold.  202-219 

Of  the  Actual  Changes  in  Fever  and  Inflammation. 

Phenomena  of  fever  and  inflammation;  Of  a  flea-bite;  Alterations  of  calibre 
of  small  arteries;  Influence  of  nerves  in  determining  the  degree  of  contraction; 
Of  the  ganglia  governing  the  calibre  of  small  arteries  ;  Nerves  to  capillary  ves- 
sels; Demonstrating  the  nerves  distributed  to  capillaries;  Mechanism  by  which 
the  capillary  circulation  of  man  and  animals  is  regulated;  General  vascular  dis- 
turbance resulting  from  local  injury ;  The  formation  of  pus  in  and  near  the  capil- 
laries in  inflammation  and  fever;  The  passage  of  blood  and  living  particles 
through  the  walls  of  capillary  vessels,  Diapedesis ;  Haemorrhage,;  Spontaneous 
movement ;  Vital  phenomena 219-248 

Common  Forms  of  Slight  Inflammation. 

Formation  of  mucus,  mucus  corpuscle;  Bioplasm  of  mucus;  Dryness  of  the 
mucous  membrane ;  impaired  sensibility ;  counter-action  ;  counter-irritation  ; 
Cracks  and  fissures  about  the  lips  ;  Principles  of  treatment ;  Conjunctiva,  inflam- 
mation of;  Treatment  of  inflamed  eyes;  Sore  throat;  treatment  of  sore  throat; 
Gargles  ;  Running  from  the  ears  ;  Inflammation  of  stomach  and  intestinal  canal  ; 
Chilblains;  Treatment;  Boils;  Carbuncle;  Changes  preparatory  to  the  occur- 
rence of  disease  ;  Concluding  remarks 248-276 

INDEX 277 


CORRIGENDIUM. 


On  page  202,  between  the  second  and  third  paragraphs,  the  follow- 
ing heading  has  been  inadvertently  omitted  : 

ON   THE    FEVERISH    AND   INFLAMMATORY   STATE. 


SLIGHT  AILMENTS: 


THEIR 


.  NATURE  AND  TREATMENT. 


INTRODUCTORY. 

EACH  one  of  us  has,  no  doubt,  suffered  at  times  from  slight  derange 
ments  of  the  health — derangements  which  are  not  dependent  upon  01 
likely  to  determine  structural  change  in  any  tissue  or  organ  in  the  body 
— due  to  temporary  disturbance,  to  an  alteration  in  the  functional 
activity  of  tissues  and  organs,  which  may  be  soon  succeeded  by  a  return 
to  the  healthy  state.  In  many  instances  the  derangement  depends  upon 
the  altered  rate  at  which  normal  phenomena  are  performed.  Perhaps,  in 
consequence  of  changes  in  the  blood  itself  or  in  the  tissues  outside  the 
vessels,  the  blood  flows  too  slowly  or  too  quickly  through  the  capillaries. 
These  tubes  often  become  unduly  distended  or  relaxed.  Disturbed 
action  in  the  adjacent  nerve- fibres  is  thereby  occasioned,  and  pain  or 
discomfort  is  in  consequence  experienced. 

Among  civilized  nations  a  perfectly  healthy  individual  seems  to  be 
the  exception  rather  than  the  rule.  I  do  not  remember  having  seen 
more  than  two  or  three  men  in  the  course  of  my  life  who  had  never 
experienced  any  form  of  illness,  and  did  not  know  what  it  was  to  feel  out 
of  sorts.  It  is  indeed  very  rarely  one  meets  with  any  one  who  has 
reached  the  age  of  thirty  who  will  not  admit  that  at  various  times  he  has 
suffered  from  many  different,  though  slight,  derangements  of  health. 
We  are  indeed  often  told  by  persons,  whose  prospects  of  longevity  are 
nevertheless  good,  that  they  have  scarcely  passed  a  week  without  the 
occurrence  of  a  very  decided  departure  from  the  healthy  state.  The 
most  healthy  among  us  occasionally  feel  unwell  and  are  less  up  to  work 
than  is  usual.  Some  complain  of  feeling  fatigued,  others  tell  you  they  are 
2*  B  17 


1 8  SLIGHT  AILMENTS  AND  CIVILIZATION. 

uncomfortable,  or  complain  of  being  irritable  and  annoyed  at  slight 
troubles,  which  would  not  ruffle  them  in  the  least  if  they  were  in  ordinary 
health.  How  few  of  those  who  take  a  very  active  part  in  the  work  of 
the  world  know  what  it  is  to  enjoy  uninterrupted  health  !  Most  have  to 
work  on  in  spite  of  lassitude,  or  headache,  or  muscular  or  nerve  pains,  or 
indigestion,  or  some  other  discomfort  which  continually  troubles  them. 
How  many  of  us  experience  a  confused  feeling,  an  indisposition  to 
mental  exertion,  a  distinct  sense  of  fatigue  after  what  we  cannot  but 
regard  as  very  moderate  mental  application  !  Many  people  take  dismal 
so-called  constitutional  walks,  not  because  they  enjoy  the  exercise  or  from 
necessity,  but  because  they  have  heard  that  this  sort  of  penal  servitude 
— walking  for  walking's  sake — is  necessary  to  keep  themselves  in  a  con- 
dition which  some  call  health.  Many  a  man  thus  imposes  upon  himself 
the  regular  performance  of  the  most  dreary  form  of  task-worl^  and  forces 
himself  to  go  through  his  monotonous  labors  when  his  inclination  would 
lead  him  to  take  rest  and  probably  to  go  to  sleep.  In  many  instances 
the  inclination  would  have  the  support  of  the  reason. 

Some,  again,  who  are  considered  to  be  in  perfect  health,  scarcely  know 
what  it  is  to  sleep  soundly  and  rise  refreshed,  with  spirits  buoyant,  ener- 
getic, with  a  desire  for  work.  Men  and  women  there  are,  and  in  every 
class  of  society,  poor  as  well  as  rich,  hardworking  as  well  as  idle,  who 
scarcely  ever  eat  without  discomfort,  and  suffer  still  more  if  they  do  not 
take  their  usual  meal.  Few,  indeed,  of  those  who  live  in  cities  pass 
through  life  without  being  troubled  with  various  derangements  connected 
with  the  action  of  the  stomach  and  intestinal  canal. 

You  will,  of  course,  desire  to  know  whether  all  these  disturbances 
are  necessary  consequences  of  our  civilization — of  our  somewhat  artificial 
mode  of  living — or  whether  by  altering  our  habits  we  could  acquire  and 
maintain  a  state  of  perfect  health.  Unquestionably  not  a  few  suffer 
because  they  'are  ignorant  of  the  proper  way  of  managing  themselves  in 
order  that  they  may  work  most  advantageously,  or  because  they  give  way 
to  habits  of  self-indulgence  as  regards  the  quantity  and  character  of  their 
food  and  drink.  Many  probably,  from  inherited  weakness  of  various 
organs,  would  suffer  more  or  less  under  any  circumstances,  and  it  is  our 
duty  to  study  the  many  ordinary  slight  ailments,  in  order  that  we  may  be 
able  to  mitigate  the  sufferings  of  our  patients,  if  we  cannot  make  them 
strong  and  vigorous.  In  this  direction  there  is  much  to  be  done,  and  I 
cannot  help  thinking  that  of  late  years,  in  our  zeal  for  pathological  dis- 
covery, we  have  devoted  less  attention  to  functional  disturbance  than  for 
the  interests  of  the  community  might  reasonably  be  looked  for  from  us, 
and  for  the  interests  of  true  medicine  might  be  expected. 

What  is  the  meaning  of  these  slight,  but  perhaps  very  frequent, 
disturbances  or  derangements  of  the  changes  which  take  place  in  an 
organism  whose  tissues  are  in  a  perfectly  normal  state?  When  any 


DERANGEMENTS  AND  DISCOMFORT.  ig 

departure  from  the  healthy  state  occurs,  it  is  obvious"  that  the  processes 
by  which  the  equilibrium  of  physiological  action  is  preserved  are  tempo- 
rarily deranged  and  out  of  order.  An  unusual  or  exceptional  change- 
increased  or  diminished  ordinary  action — results.  In  many  instances 
some  time  must  elapse  before  the  exceptional  gives  place  to  the  ordinary 
activity,  and  by  slight  excess  of  action  in  one  or  other  direction  the 
balance  is  restored. 

A  little  too  much  food,  or  food  of  a  bad  kind,  or  badly  cooked,  or 
food  eaten  at  the  wrong  time,  or  too  quickly — a  glass  of  bad  wine,  bad 
milk,  or  bad  water,  to  say  nothing  of  a  dry  east  wind,  or  a  cold  damp 
atmosphere,  has  occasioned  such  disturbance  in  the  normal  changes  in 
the  body,  as  to  cause  even  the  strongest  and  exceptionally  healthy 
to  feel  for  a  time  far  from  well.  Every  generation  has  thus  suffered,  and 
we  have  no£  yet  discovered  exactly  how  a  healthy  person  should  proceed 
so  as  to  keep  every  organ  and  every  tissue  in  his  body  in  a  perfectly 
healthy  state  under  the  necessarily  varying  conditions  to  which  it  is 
exposed,  so  that  each  may  continue  to  act  for  the  longest  possible  time, 
and  all  gradually  fail  together  in  old  age,  until  at  last  action  ceases  in 
natural  and  inevitable  death. 

As  it  is  our  particular  work  in  life  to  reduce  disease  and  suffering  to 
the  utmost  extent  that  is  possible,  it  is  undoubtedly  our  duty  to  care- 
fully study  and  investigate,  as  far  as  we  are  able  to  do  so,  the  nature  of 
such  slight  aches,  pains,  discomforts,  and  derangements  from  which  nearly 
all  suffer.  Not  a  few  people  magnify  their  slight  ailments, but,  on  the  other 
hand,  some  persons  are  no  doubt  inclined  to  under-estimate  the  import- 
ance of,  or  to  ignore  altogether,  aches,  pains,  and  disturbances,  the  early 
recognition  of  which  might  be  of  great  advantage,  by  enabling  the  doctor 
to  interfere  at  once,  and  perhaps  prevent  serious  illness,  or  even  save  that 
particular  life. 

You  will  certainly  be  very  frequently  called  upon  to  prescribe  for 
slight  ailments,  and  you  will  often  be  asked  how  this  and  that  bodily 
derangement  or  discomfort  may  be  avoided,  upon  what  it  depends,  and 
whether  it  is  not  indicative  of  some  change  more  serious  than  mere 
temporary  disturbance  of  ordinary  action.  You  will  be  expected  to 
fully  explain  how  many  a  slight  ache  or  pain  is  caused,  and  you 
will  often  be  asked  to  lay  down  rules  of  health,  by  the  practice  of  which 
it  may  be  avoided  in  the  future.  Very  disappointed  will  the  sufferer 
feel  if  you  make  light  of  his  suffering,  and  dismiss  him  with  the 
suggestion  that,  being  only  functional  derangement,  it  is  of  no  conse- 
quence. A  little  study  and  intelligent  observation  among  sick  people 
will  teach  you  not  to  be  too  off-hand  in  giving  advice,  and  will  suffice  to 
impress  upon  you  the  fact  that  very  grave  symptoms  and  the  most 
excruciating  pain  may  result  from  temporary  derangements  of  no  real 
consequence,  and  that,  on  the  other  hand,  the  most  terrible  morbid 


2O  GENERAL   REMARKS. 

changes  in  important  organs  may  exist  for  years,  and  run  their  course 
without  the  patient  being  cognizant  of  any  unusual  symptoms,  or  con- 
scious that  anything  in  his  organism  had  been  going  wrong. 

I  propose,  then,  that  these  lectures  should  be  devoted  to  the  considera- 
tion of  the  nature  and  treatment  of  slight  ailments.  Could  we  examine 
the  tissues  ever  so  minutely,  it  is  doubtful  whether  we  should  discover 
the  slightest  departure  from  the  healthy  state.  No  structural  change 
whatever  is  induced,  and  even  in  cases  in  which  there  is  decided  depart- 
ure from  the  normal  physiological  action,  and  where  considerable  pain 
and  distress  may  be  experienced,  the  accumulation  in  the  blood  of  some 
product  that  should  be  quickly  eliminated, — a  slightly  altered  state  of 
the  fluid  that  transudes  through  the  capillary  walls  and  bathes  the  tissue 
elements, — is  probably  all  that  would  be  found,  and  would  indeed  be 
quite  sufficient  to  account  for  the  symptoms. 

In  the  course  of  our  inquiry  questions  of  the  greatest  interest  will 
present  themselves,  and  although  the  present  state  of  our  knowledge 
does  not  enable  us  to  give  a  full  and  satisfactory  explanation  of  all  the 
phenomena,  say,  of  an  Ordinary  Cold 'or  a  Sick  Headache,  I  feel  sure  that 
a  more  full  consideration  of  the  slight  disturbance  of  physiological  actions 
which  are  continually  occurring  even  in  the  healthiest  among  us,  will 
assist  us  in  understanding  those  more  complex  changes  which  occur  in 
actual  disease. 

The  plan  I  propose  to  adopt  will  not  only  enable  me  to  bring  under 
your  notice  thus  early  in  my  course  some  of  the  simplest  and  most 
common  derangements  you  will  be  called  upon  to  correct,  but  I  shall  be 
able  to  direct  your  attention  to  practical  matters  of  great  importance 
with  regard  to  the  action  of  remedies  and  methods  of  prescribing  and 
administering  many  ordinary  medicines — matters  of  greater  importance 
than  ever  in  these  days,  when  so  few  among  you  enjoy  the  advantages 
formerly  gained  by  apprenticeship,  and  become  acquainted  with  the  art 
and  mystery  of  preparing  drugs  and  compounding  medicines  and  dis- 
pensing pills  and  potions. 

I  shall  make  use  of  very  few  learned  terms,  and  when  obliged  to 
employ  hard  words  shall  give  their  exact  meaning  and  derivation,  and  I 
shall  try  to  describe  the  derangements  I  have  to  consider  in  the  simplest 
manner  possible.  In  case  any  of  you  should  think  I  am  too  outspoken 
as  regards  the  confessions  I  shall  have  to  make  of  ignorance  concerning 
the  real  nature  of  some  of  the  simplest  and  most  common  of  the 
slight  ailments,  I  would  only  remark  that,  as  there  is  so  much  real 
knowledge  in  medicine,  and  as  the  labors  of  our  predecessors  have 
established  so  many  great  truths  and  principles,  we  may  surely  freely 
admit  that  there  are  many  things  which  we  do  not  know,  without  fear 
of  losing  the  confidence  of  the  public.  In  my  opinion,  it  is  the  very 


ON  SLIGHT  AILMENTS.  21 

worst  thing  for  the  interest  of  true  medicine  when  any  of  her  followers 
act  in  such  a  way  as  to  lead  those  who  are  completely  ignorant  of  our 
work  to  suppose  that  we  have  acquired  in  some  mysterious  way  knowl- 
edge that  we  cannot  communicate  to  others,  or  that  we  have  means  of 
investigating  disease  which  cannot  be  pursued  or  understood  by  ordinary 
mortals.  We  have  no  remedies  of  a  secret  nature,  no  occult  arts  of 
preparing  or  combining  them  so  as  to  increase  their  virtues.  All  that  we 
know  can  be  learned  by  any  one  who  chooses  to  spend  the  time  and  take 
the  trouble  requisite  for  mastering  our  art  and  the  branches  of  science 
upon  which  it  is  based. 

There  is  no  doubt  still  manifest  a  slight  tendency  here  and  there  to 
credit  some  of  us  with  the  possession  of  mysterious  power  to  control 
disease,  but  there  is  no  excuse  for  this.  Whenever  naturally  self-reliant 
enthusiasts  act  as  if  they  were  really  the  fortunate  and  favored  pos- 
sessors of  a  power  of  detecting  and  controlling  morbid  processes  that  was 
not  to  be  acquired  by  other  men,  the  advance  of  medical  truth  will  be 
retarded.  In  every  age  self-confidence  has  commanded  faith  and  devo- 
tion, and  with  the  aid  of  these  the  evolution  of  the  extraordinary  and 
marvellous  from  the  ordinary  and  intelligible  is  not  difficult.  I  should 
feel  very  sorry  if  in  after  days  I  should  discover  that  any  of  my  pupils 
have  deviated  from  the  right  path,  as  some  who  have  studied  medicine 
had  done,  and  had  tried  to  make  people  believe  they  possessed 
powers  and  influences  over  disease  which  they  did  not  possess.  So 
terrible  a  falling  away  from  the  high  standard  raised  by  our  predecessors 
and  handed  down  to  us  would  be  a  sad  disgrace,  and  is  most  painful  to 
contemplate. 

Of  the  patients  who  come  under  our  care,  many  will  be  the  subjects  of 
but  slight  ailments,  with  the  general  nature  of  which  any  well-educated 
•and  experienced  practitioner  would  no  doubt  be  well  acquainted.  But 
if  you  go  into  practice  fresh  from  the  wards  and  the  pathological  depart- 
ment, and  at  once  undertake  the  treatment  of  sick  people, — if  you 
pass  from  the  investigations  of  important  structural  changes  to  the  prac- 
tical consideration  of  functional  disturbance,  and  especially  if  you  look 
too  exclusively  from  a  purely  scientific  stand-point,  you  will  meet  with 
many  things  that  will  puzzle  you.  The  patients  you  treat  will  not  be 
satisfied,  and  you  will  be  disappointed  and  annoyed,  because  they  are 
not  contented  with  the  advice  you  give.  Perhaps  you  will  feel  in  conse- 
quence out  of  heart  or  thoroughly  disgusted  with  practical  professional 
work. 

It  has  been  said  that  the  physician  should  be  a  consolation  to  the 
patient,  but  many  a  physician  fresh  from  the  study  of  severe  forms  of 
disease  would,  I  fear,  afford  poor  comfort  to  a  dyspeptic,  or  to  a  person 
suffering,  say,  from  functional  nervous  disturbance,  and  would  hardly 
know  what  to  say  to  a  patient  in  whose  body  he  could  discover  no  actual 


22  INTEREST  IN  THE   PATIENT. 

disease  of  tissues  or  organs.  The  patient  might  describe  many  unpleas- 
ant and  even  alarming  sensations  and  symptoms,  which  to  him  were  of 
course  of  grave  consequence,  and  all  the  comfort  that  he  could  get  from 
such  a  medical  adviser  might  be  that,  as  there  was  no  organic  disease,  he 
might  go  away  and  bear  his  complaints  as  best  he  could.  Medical 
advisers  of  purely  anatomical  and  pathological  habits  of  mind  are  cer- 
tainly apt  to  disappoint  or  even  offend  unscientific  patients,  and,  without 
deserving  it,  gain  for  themselves  the  unenviable  reputation  of  being 
thoughtless  and  unkind — regardless  of  others'  suffering,  and,  if  not 
objectionable,  very  far  from  agreeable  ministers  of  relief.  People  do 
strongly  object  to  follow  the  advice  of  such  advisers,  however  correct  it 
may  be ;  and  perhaps  the  least  unfriendly  among  the  patients  of  such  a 
doctor  would,  out  of  kindness  and  in  the  most  quiet  and  confidential 
way,  recommend  him  as  soon  as  possible  to  change  his  vocation. 

You  ought,  therefore,  to  learn  how  to  investigate  the  nature  of 
slight  ailments  and  how  to  relieve  them,  and,  if  the  conditions  which 
give  rise  to  them  are  beyond  our  means  of  control,  how  to  reduce  the 
severity  of  the  patient's  sufferings.  If  the  patient's  malady  is,  unfor- 
tunately, ever  so  intractable  or  incurable,  he  will  be  much  more  grateful 
to  you  for  your  attention,  and  for  doing  what  you  can  to  relieve  him, 
than  he  would  be  if  you  favored  him  with  the  most  learned  and 
elaborate  disquisition  concerning  his  case,  even  if  it  was  accompanied 
with  the  demonstration  that  his  illness  was  profoundly  interesting  and 
afforded  an  exceptionally  perfect  illustration  of  very  remarkable  patho- 
logical phenomena.  You  will  generally  find  that  if  a  man  has  pain  in 
his  stomach,  especially  if  accompanied  with  excruciating  spasm,  he  will 
not  be  satisfied  with  the  assurance  that  he  will  be  better  when  the  wind 
is  dispersed.  However  interested  we  may  be  in  studying  the  natural 
history  of  disease,  the  patient  desires  our  assistance  to  disperse  wind 
that  torments  him,  and  wants  remedies  which  will  relieve  his  sufferings 
as  soon  as  possible.  I  think  you  will  agree  in  the  opinion  that  such  a 
patient  is  not  more  unreasonable  than  most  doctors  themselves  would 
be  under  similar  circumstances.  If  you  know  your  work,  you  can  be  of 
use  both  in  getting  rid  of  the  flatus  and  in  relieving  the  pain.  If  from 
ignorance  of  the  use  of  simple  remedies  you  tell  the  patient  that 
nothing  can  be  done,  the  chances  are  that  he  will  go  to  some  intelligent 
person,  professional  or  non-professional,  who  may,  perhaps,  give  him  a 
close  of  Bicarbonate  of  potash  or  some  Sal  volatile.  He  is  at  once 
relieved,  gets  well  in  the  course  of  a  few  hours,  and  loudly  praises  the 
adviser  of  the  successful  treatment.  On  the  other  hand,  anything  but 
praise  in  such  a  case  would  fall  to  your  share.  I  fear  that  the  patient 
would  give  you  a  very  bad  character,  and  he  might  possibly  speak  of  you 
as  a  most  ignorant  person  and  incompetent  practitioner.  Though,  per- 
haps, not  acquainted  with  the  great  value  of  such  simple,  commonplace 


WE  SHOULD  BE  IN  GOOD  HEALTH.  2$ 

things  as  Bicarbonate  of  potash  and  Sal  volatile,  and  some  other  simpfe 
medicines  which  are  very  efficacious  in  curing  various  unpleasant  aches 
and  pains,  you  might  nevertheless  be  well  informed  as  regards  the  manage- 
ment of  serious  cases,  and,  in  fact,  a  well-informed  and  good  practitioner. 
Those  of  you  who  are  going  to  take  part  in  country  practice  ought  to 
be  especially  careful  to  try  to  do  all  you  can  to  please  as  well  as  to  help 
your  patients.  There  may  be  no  other  medical  adviser  within  many 
miles,  and  it  is  most  unfortunate  if  any  of  the  people  in  your  neigh- 
borhood should  be  prejudiced  against  you.  You  must,  indeed,  think 
over  people's  individual  peculiarities,  be  ready  to  pardon  their  suscepti- 
bilities, and  try  your  utmost  not  to  offend  them.  The  most  painful 
differences  have  been  occasioned  from  want  of  care  on  this  head ;  and 
many  a  coolness  between  patient  and  practitioner,  which  has  lasted  for 
years,  and  has  caused  much  suffering  and  misery,  might  have  been 
altogether  avoided,  if  the  practitioner  had  exhibited  a  little  amiability 
and  exercised  ordinary  caution  and  self-control  early  in  his  acquaint- 
anceship. Not  a  few  differences  with  patients  may  sometimes  be  traced 
to  the  practitioner's  ignorance  of  common  things  he  ought  to  know,  or  to 
an  attempt  upon  his  part  to  introduce  new  customs  in  dealing  with  his 
patients  with  which  they  are  not  familiar. 

You  will  find  some  useful  hints  to  guide  you  in  country  practice  and 
much  information  on  conducting  different  branches  of  practice  in  a  very 
useful  little  book  to  those  about  to  enter  upon  the  practical  duties  of 
professional  life,  lately  written  by  Dr.  Diver,  entitled  "The  Young 
Doctor' s  Future  ;  or,  What  shall  be  my  Practice?  " 

But,  further,  the  study  of  the  slight  ailments  is  of  no  small  import- 
ance to  medical  men,  for  it  is  of  the  greatest  consequence  that  we  our- 
selves should  be  in  good  health.  Attendants  of  the  sick  should  them- 
selves be  well,  and  each  one  of  us  should  recognize  the  importance  of 
keeping  himself  in  a  healthy  state,  that  he  may  be  cheerful  and  hopeful 
in  the  presence  of  the  sick.  It  never  does  for  the  doctor,  while  listening 
to  the  sorrows  of  his  patients,  to  be  continually  reminded  of  his  own 
discomforts,  and  constantly  thinking,  if  he  does  not  actually  say,  that  he 
is  far  worse  than  his  patient,  and  more  worthy  of  attention,  sympathy, 
and  commiseration.  The  sufferer  suffers  less  if  he  has  healthy,  cheerful 
people  about  him.  Dwelling  on  the  fact  of  pain,  and  talking  about  it, 
seems  to  increase  it.  Many  patients  suffering  from  temporary  derange- 
ments are  in  a  low,  despondent  state.  Such  a  frame  of  mind  is  more 
commonly  due  to  temporary  deranged  action  of  the  stomach  and  liver 
than  to  any  other  circumstance.  Though  you  may  be  equally  or  even 
more  dyspeptic  and  may  feel  very  wretched,  you  must  be  careful  not  to 
add  to  the  general  depression  by  discoursing  about  your  own  ailments, 
but  must  encourage  and  cheer  the  patient,  and  speak  hopefully.  All 


24  A  TTENTION  AND  KINDNESS. 

this  is  not  very  easy  to  do  if  we  are  not  well.  The  doctor  who  is  suffer- 
ing aches  and  twinges  is  to  be  pitied,  for  he  must  not  allow  himself  to 
complain.  He  must  not  make  wry  faces  while  he  is  inquiring  into  his 
patient's  case.  An  ailing  or  hypochondriacal  doctor  will  be  of  little 
use,  will  get  into  discredit  with  patients,  and  will  be  disappointed  with 
himself;  and  it  will  probably  happen  that  some,  it  may  be,  ill-informed, 
but  more  worldly-minded  medical  authority  in  his  neighborhood  will 
get  the  patients  who  ought  to  be  in  his  more  deserving  hands.  This, 
I  fear,  is  not  unfrequently  the  secret  of  many  a  failure  in  practice. 

Those  of  you  who,  like  many  excellent  men  who  have  preceded  you, 
feel  inclined  to  condemn  the  delicate  attention,  the  excessive  care,  the 
extreme  solicitude  for  minute  perturbations  of  sensation  or  emotion  of 
the  invalid,  characteristic  of  some  very  successful  and  favorite  doctors, 
should  pause,  and  try  to  look  a  little  from  the  patient's  point  of  view. 
Even  a  philosopher  who  feels  ill,  though  he  may  be  sure  that  there  is 
not  much  the  matter  with  him,  may  nevertheless  desire  some  skilled 
and  experienced  medical  adviser  who  will  appreciate  his  aches  and 
pains,  who  will  consider  his  complaint,  and  listen  patiently  to  the  story 
of  his  woes,  -who  will  take  a  cheerful  view  of  his  case,  and  express  him- 
self accordingly,  instead  of  suggesting  possibilities  of  pathological 
degeneration  in  the  gloomiest  phraseology.  You  may  be  able  to  relieve 
many  a  sufferer  by  suggesting  some  very  simple  remedy.  A  dose  of 
bicarbonate  of  potash  or  lime-water  after  meals  may  be  all  that  is 
requisite  to  restore  him  to  health.  Little  may  be  needed,  but  still  that 
little  assistance  is  required. 

Many  of  the  apparently  slight  disturbances  or  ailments  may  be  due 
to  some  grave  pathological  change,  which  would  be  entirely  passed  over 
by  one  who  had  had  little  experience  in  medical  observation,  but  would 
be  full  of  significance  to  the  well-informed  practitioner.  On  the  other 
hand,  we  often  find  that  apparently  serious  illness  is  really  due  to  tem- 
porary and  functional  derangement  only.  Do  not,  therefore,  be  too 
hasty  in  giving  an  opinion  concerning  the  import  of  uncertain  and  in- 
definite symptoms.  You  should  remember  that  the  most  perfect 
machines  sometimes  go  wrong  without  a  flaw  being  discoverable  just 
before  the  occurrence,  it  may  be,  of  a  complete  breakdown.  No 
wonder  that  %he  tissues  and  organs  and  the  marvellously  minute  and 
delicate  structures  of  a  living  being  may  fail  in  a  hundred  ways  without 
giving  any  notice  even  to  their  owner.  The  most  careful  scrutiny  and 
minute  examination  may  fail  to  demonstrate  any  fault  or  flaw;  nay, 
even  after  the  body  had  ceased  to  work,  after  its  death,  the  changes 
resulting  in  its  destruction  may  elude  the  most  careful  investigation. 
We  know  that,  for  example,  hydrocyanic  acid,  by  its  action  on  the 
nervous  system,  will  kill  a  living  organism  in  a  few  seconds,  but  as  to 
tne  exact  changes  which  the  acid  works  in  the  nerve  structures  and 


TACT  AND    TREATMENT.  2$ 

their  living  particles,  we  know  nothing.  The  same  is  true  of  many 
other  modes  of  death.  The  flaws  existing  in  tissues  in  disease  are  not 
always  to  be  demonstrated,  though  possibly  many  at  least  may  be 
demonstrable,  if  we  only  knew  exactly  how  to  render  them  evident  and 
distinct. 

Practitioners  who  will  not  endeavor  to  help  their  patients  who  are 
suffering  from  slight  ailments  had  better  not  attempt  to  practise 
medicine  at  all,  because  they  will  almost  certainly  fail,  seeing  that  a 
large  percentage  of  our  patients,  fortunately  for  themselves,  do  not 
suffer  from  grave  pathological  changes.  •  Nevertheless  they  require 
intelligent  medical  assistance.  There  is  not  one  amongst  us  who  gives 
his  attention  to  those  patients  only  who  are  suffering  from  very  serious 
forms  of  disease.  You  must  therefore  understand  the  nature  of  slight 
derangements,  and  you  must  know  how  to  relieve  them.  You  must  not 
treat  the  complaining  patient  with  contempt,  and  tell  him  there  is 
nothing  of  any  consequence  the  matter,  and  that  he  may  go  about  his 
business.  If  we  behave  in  this  manner  the  public  will  lose  confidence 
in  us,  and  great  numbers  of  people  will  seek  and  accept  advice  from 
mere  pretenders,  and  from  wiseacres  who  profess  to  discover  the  most 
wonderful  and  exceptional  phenomena  in  very  ordinary  cases,  or  who, 
while  thus  trying  to  gain  the  ear  of  the  patient,  make  the  most  of  every 
opportunity  of  casting  a  slur  on  those  who  have  honestly  studied  and 
practised  their  profession.  Knowing  little  or  nothing  of  morbid  changes, 
and  of  the  sciences  upon  which  the  investigation  and  treatment  of 
disease  rests,  many  of  these  professing  healers  are,  in  a  way,  extremely 
clever,  and  not  a  few  have  the  advantage  of  a  marvellous  development 
of  that  peculiar  mental  endowment  called  "tact" — a  most  desirable 
possession  for  every  one  who  has  to  treat  and  take  care  of  sick  people, 
if,  in  addition,  he  is  honest  and  good.  I  would  have  you  take  note,  how- 
ever, that  this  word  "  tact  "  has  a  very  comprehensive  and  elastic  mean- 
ing, and  is  in  these  days  equally  applied  to  an  honest  desire  on  the  part 
of  any  one  to  avoid  wounding  the  feelings  of  a  sensitive  person,  or  need- 
lessly vexing  such  an  one  when  it  is  necessary  to  communicate  un- 
pleasant things,  and  to  the  successful  exercise  of  glaring  imposture  and 
pitiless  humbug.  One  now  and  then  gets,  in  a  sense,  an  instructive, 
though  a  very  painful  and  profitless  lesson,  as  to  the  means  by  which 
the  good  opinion  of  people  unlearned  in  medical  ajid  other  matters  may 
be  gained  by  a  practitioner  who  is  sadly  deficient  in  knowledge  and  in 
experience,  and  who  is  perfectly  conscious  of  his  defects,  but  knows 
well  how  to  make  up  for  them.  A  master  of  tact,  and  determined  to 
avail  himself  of  the  advantage  he  thus  possesses  in  the  struggle  for 
existence,  he  convinces,  he  persuades,  and,  in  short,  flourishes  where 
many  a  good  man  would  fail,  and,  perhaps,  where  many  such  have 
already  failed.  Nevertheless,  do  not  let  me  lead  you  to  conclude  that 
3 


26  QUACKERY  AND    TACT. 

tact  is  another  name  for  humbug,  any  more  than  that  kindness  and 
politeness  imply  insincerity;  but  it  is  only  too  true  that  some  makers  of 
fortunes  have  been  indebted  for  their  success  to  cunning,  cuteness,  and 
tact,  rather  than  to  hard  work,  goodness,  or  intellectual  power ;  and  he 
who  thinks  very  highly  of  tact,  and  acts  upon  his  opinion,  must  be  very 
careful  lest  he  slide  too  far  down  the  incline,  which  may  lead  him  on 
from  the  display  of  tact  to  the  habitual  exercise  of  humbug,  and  at  last 
to  giving  way  to  utter  heartlessness  and  selfishness  of  the  lowest  order. 

Unless  the  highly  competent  and  intelligent  practitioner  exercise  due 
care  as  regards  what  he  says  and  what  he  leaves  unsaid,  he  may  entirely 
fail  to  gain  the  confidence  of  his  patient.  Many  a  good,  honest,  and 
intelligent  man  unconsciously  helps  to  drive  the  patient  into  bad  hands. 
Grave  pathological  changes  may  be  overlooked,  and  trifling  aches  and 
pains  magnified  by  the  patient  into  indications  of  serious  and  danger- 
ous disease — from  want  of  care  and  attention  as  regards  the  manner  in 
which  the  practitioner  expresses  himself  concerning  aches  and  pains. 

But  there  are  persons  who  would  be  easily  influenced  by  what  the 
quack  says,  who  would  go  away  from  the  honest,  well-informed  medical 
practitioner,  with  the  idea  that  he  knew  nothing  whatever  about  his 
business,  and  was  quite  ignorant  of  the  nature  of  the  changes  taking 
place  in  the  organism,  and  of  the  method  by  which  these  changes  might 
be  modified  when  they  were  not  properly  performed.  This  is  unfor- 
tunate, but  there  is  no  help  for  it.  Every  upright  practitioner  has  been 
placed  in  this  most  unhappy  position  more  than  once  in  his  life. 
Should  you  find  yourselves  so  situated,  the  best  thing  is  to  say  very 
little,  and  be  as  patient  as  possible,  leaving  matters  to  be  set  right  by 
time.  While  doing  our  utmost  to  preserve  and  extend  the  high  repute 
always  enjoyed  by  the  medical  profession,  we  must  be  careful  not  to  play 
into  the  hands  of  pretenders,  and  this  we  shall  certainly  do  if  we  need- 
lessly offend  fanciful  and  crotchety  patients,  for  by  thus  acting  we  prac- 
tically dismiss  them  to  be  preyed  upon  by  quacks. 

There  are  few  matters  of  greater  interest  or  consequence  to  us  than 
the  consideration  of  the  manner  by  which  we  may  succeed  in  gaining 
the  confidence  of  our  patients,  without  making  promises  which  cannot 
be  fulfilled,  and,  indeed,  without  saying  anything  of  which  an  upright, 
intelligent,  and  high-minded  gentleman  of  kindness  and  consideration 
could  in  the  least  degree  feel  ashamed.  Some  men  have  the  natural 
gift  of  inspiring  confidence  at  once,  just  as  others  have  unfortunately  to 
contend  with  natural  defects  resulting  in  exciting  in  the  minds  of  others 
anything  but  confidence.  Still  you  must  bear  in  mind  that  he  who  is  to 
afford  real  help  to  people  as  a  medical  adviser,  must  be  trusted  and 
believed  in  by  his  patients.  It  is,  therefore,  our  duty  to  study  and 
train  ourselves  so  that  we  may  inspire  confidence  in  those  who  place 
themselves  under  our  care.  In  this  endeavor  we  are,  so  to  say,  often 


MEDICAL  HUMBUG,  27 

heavily  weigh'ted.  To  gain  the  esteem,  especially  of  people  unlearned 
in  matters  medical,  it  may,  indeed,  be  necessary  to  promise  more  in  the 
way  of  cure  than  truthfully  a  man  of  sound  judgment  would  be  able  to 
do.  We  are  often  placed  at  a  disadvantage,  and  a  vulgar,  ignorant  pre- 
tender, brimful  of  assurance  and  conceit,  will  sometimes  succeed  in 
gaining  the  confidence  even  of  an  intelligent  patient,  when  men  of  a 
higher  order  of  mind  -have  hopelessly  failed.  In  not  a  few  instances 
the  patient  pays  most  dearly  for  the  mistake  he  has  made,  but  it  may 
be  long  before  he  finds  out  that  he  has  made  a  mistake  at  all,  and  still 
longer  before  he  confesses  he  has  done  so  when  he  does  find  it  out.  It 
is  the  conceit  rather  than  the  ignorance  of  the  dupe  which  renders  him 
an  easy  victim  of  the  quack. 

On  Quackery  and  Medical  Humbug. — To  those  of  us  who  have 
passed  thirty  years  or  more  working  and  thinking  amongst  sick  people, 
and  studying  with  the  aid  of  accurate  scientific  instruments  the  nature  of 
the  actual  phenomena  occurring  in  the  tissue  elements,  and  in  the  fluids 
of  the  body  in  departures  from  the  healthy  state,  it  seems  as  extraor- 
dinary as  it  is  disappointing,  that  men  of  undoubted  intelligence  and 
well  acquainted  with  the  ways  of  the  world,  should  sometimes  select  for 
their  medical  adviser,  not  only  an  ignoramus,  but  a  medical  pretender — an 
impudent  fellow,  who  acts  up  to  the  conviction  that  if  he  only  talks  non- 
sense with  sufficient  audacity  he  will  prevail,  because  even  among  highly 
educated  people,  it  is  very  exceptional  to  meet  with  one  who  is  suffi- 
ciently acquainted  with  anatomy,  physiology,  and  chemistry  to  detect 
the  true  character  of  his  insolent  balderdash.  But  such  complaint  is 
not  new.  Galen  ("  Meth.  Med.,"  1.  i.)  remarks  in  the  time  of  the 
Roman  Empire,  "  What  gives  vogue  to  a  physician  is  not  science,  but 
skill  in  flattery.  To  him  who  is  the  best  sycophant,  everything  becomes 
easy.  To  him  every  door  is  open.  In  a  short  time  he  becomes  rich 
and  powerful."  "  The  asses  of  Thessalus  had  parcelled  out  the  art  of 
healing  into  the  most  minute  subdivisions  of  practice.  Rome  swarmed 
with  special  curers.  Some,  for  instance,  confined  their  practice  to  the 
treatment  of  the  uvula,  or  the  eyelashes,  or  certain  kinds  of  cutaneous 
eruptions.  Some  restricted  their  attention  to  the  treatment  of  ag,ed 
men,  others  to  that  of  the  strong  and  robust.  Some  would  cure  only 
with  herbs,  others  by  means  of  gymnastic  exercises." 

One  would,  however,  have  thought  that  certain  people  of  intelligence 
and  culture  would  have  preferred  as  their  medical  attendant  one  whose 
position  alone  rendered  it  evident  that  he  could  not  be  a  quack  or  an 
ignoramus,  and  at  least  take  the  very  little  trouble  required  to  discover 
among  the  four  or  five  hundred  public  medical  officers,  whose  work 
and  repute  are  known,  or  at  least  among  the  two  or  three  thousand 
medical  practitioners  whose  training  and  character  are  recognized,  one 
adviser  who  would  not  only  treat  them  with  judgment  and  intelligence, 


28  VULGARITY  MISTAKEN  FOR    GENIUS. 

but  satisfy  and  please  them  in  other  ways.  Instead  of  taking  the  little 
trouble  required,  how  often  is  the  recommendation  of  some  old  woman, 
who  declares  she  has  been  cured  of  the  most  serious  and  extraordinary 
maladies  after  the  most  distinguished  members  of  the  profession  had 
completely  failed,  taken  and  acted  upon  without  further  inquiry.  It  is 
quite  extraordinary  what  large  practices  may  be  made  in  a  short  time  by 
the  puffing  of  influential  people,  not  one  of  whom  has  perhaps  taken 
the  trouble  to  ascertain  whether  the  practitioner  so  extolled  is  really 
deserving  or  not  of  the  high  praise  and  recommendation  he  has  had 
the  good  luck  to  enjoy. 

Sometimes  it  would  appear  that  some  extraordinary  vulgarity  of 
manner  on  the  part  of  the  fortunate  doctor  had  been  set  down  as 
indicating  originality  of  mind  or  unusual  genius.  The  art  of  looking 
wise  and  saying  nothing  seems  to  be  the  secret  of  success  in  not  a  few 
instances.  Sometimes  success  in  small  talk,  a  bustling  manner  indicative 
of  overwhelming  business;  while,  occasionally,  peculiarity  or  perfection 
of  dress  appears  to  have  won  the  respect  and  confidence  of  patients, 
and  secured  to  the  elegant  doctor  a  considerable  practice.  You  will 
not,  however,  feel  astonished  at  all  this  if  you  consider  how  very 
ignorant  of  all  subjects  bearing  in  any  way  upon  physiology  and 
medicine  are  the  generality  even  of  so-called  well-informed  people. 
Not  a  few  of  the  intellectual  classes,  the  leaders  of  thought,  great 
classics  and  mathematicians,  lawyers,  public  speakers  and  writers,  do  not 
take  the  slightest  interest  in  any  department  of  natural  knowledge,  and 
are  so  incapable  of  entering  into  scientific  modes  of  thought  and  work, 
that  they  can  be  deceived  and  cheated  by  the  most  commonplace 
pretender.  The  efficacy  of  the  thousandth,  or  millionth,  or  decillionth 
of  a  grain  of  charcoal  is  deemed  by  them  a  question  open  to  inquiry 
and  to  be  determined  by  experiment.  The  utter  suppression  of  ex- 
periments upon  the  lower  animals  seems  to  them  but  reasonable,  mag- 
nanimous, and  right.  The  ignorance  and  prejudice  fostered  by  the 
teaching  and  advice  of  persons  wholly  ignorant  of  science  and  by 
nature  strongly  opposed  to  all  attempts  to  inquire  into  the  nature  of 
things,  constitute  the  chief  obstacles  to  sanitary  improvement,  and 
encourage  the  maintenance  of  conditions  adverse  to  health  and  the  per- 
petuation of  diseases  still  annually  destroying  thousands,  but  which 
ought  long  ago  to  have  become  unknown  in  England. 

It  is  easy  for  those  who  make  light  of  the  facts  of  medical  and  sani- 
tary science,  and  who  pretend  to  believe  in  the  virtue  of  minute  globules, 
to  retort  by  accusing  us  of  attempting  to  constitute  ourselves  into  a  sort 
of  trades-union,  which  condemns  all  who  do  not  fall  in  with  its  views. 
The  writers  in  our  public  journals,  however,  ought  to  be  able  to  see 
through  such  false  charges  and  commonplace  cries,  and  expose  them. 
But  to  condemn  as  a  trades-union  a  body  of  men  engaged  in  the  fur- 


DECILLIONTHS  OF  A    GRAIN.  2g 

therance  of  the  greatest  of  all  blessings,  the  health  of  the  community,  is 
most  unjust.  Our  profession  encourages  and  rewards  individual  merit, 
and  allows  and  sanctions  individual  success, — permits  the  freest  com- 
petition between  its  members,  limits  neither  the  hours  of  work  nor  the 
freedom  of  thought, — encourages  all  to  aspire  to  equal,  and,  if  it  may 
be,  to  excel  the  greatest  of  those  whose  lives  and  works  are  recorded 
in  its  annals, — endeavors  to  protect  the  unlearned  and  uninstructed 
from  imposition  and  wrong,  and  refuses  to  sanction  on  the  part  of  its 
members  any  secret  method  of  healing,  however  useful  it  may  be,  or  the 
use  of  any  medicine  the  ingredients,  composition,  and  method  of  pro- 
ducing which  are  not  published  to  the  world  for  the  advantage  of  all. 
There  is  not  the  faintest  justification  for  urging  a  complaint  of  the 
kind  against  the  medical  profession.  Anything  like  what  is  called  trades- 
unionism  amongst  us,  if  possible,  is  one  of  the  most  improbable  of 
improbable  eventualities. 

We  only  insist  that  the  real  knowledge  which  has  been  handed  down 
to  us,  and  which  is  still  being  added  to  by  the  work  of  thousands  of  practi- 
tioners in  all  parts  of  the  world,  shall  not  be  considered  in  any  way 
comparable  with  or  related  to  any  so-called  medical  systems  which  are 
based  upon  the  assumption  that  any  effects  result  from  the  exhibition  of 
quantities  of  various  medicines  supposed  to  amount  to  a  millionth  of  a 
grain  or  less.  We  maintain  that  the  dicta  upon  these  and  other  medical 
matters  received  as  true  by  a  section  of  the  public  are  opposed  to  facts 
of  anatomy,  physiology,  and  chemistry,  to  observation  and  experiments, 
by  which,  on  the  other  hand,  the  principles  upon  which  medicine  is 
based  are  continually  being  tested  and  verified  or  modified. 

To  ascertain  whether  such  a  quantity  as  the  decillionth  of  a  grain 
acts  in  any  way  is  impossible,  any  attempt  to  do  so  would  be  foolish, 
since  no  one  can  be  sure  that  one-decillionth  of  a  grain  of  anything  in 
the  world  can  be  obtained.  Such  supposed  fractional  part  is  beyond 
the  limits  of  physiological,  chemical,  or  other  method  of  investigation. 
It  is  invisible,  intangible,  undemonstrable,  and  as  a  medicine  exists  only 
in  imagination,  and  can  be  proved  by  assertion  only.  In  fact,  it  is  not 
even  possible  to  imagine  particles  of  a  degree  of  minuteness  con- 
siderably less  extreme  than  these.  But  it  is  useless  to  attempt  to  reason 
on  such  absurdities.  I  am  ready  to  admit  that  there  are  persons  who 
believe  that  the  decillionth  of  a  grain  of  opium  will  produce  an  effect 
upon  man's  organism,  just  as  there  are  people  who  hold  that  the  earth 
is  flat,  that  living  things  are  machines,  that  spontaneous  generation 
occurs,  that  vaccination  is  detrimental,  and  a  number  of  things  which 
may  have  been  conclusively  proved  or  disproved,  as  the  case  may  be,  or 
concerning  which  there  can  be  no  evidence  one  way  or  the  other,  or 
which  are  altogether  beyond  the  reach  of  thought. 

In  this  country  we  are  proud  of  what  is  called  liberty  of  opinion,  and 
3* 


3O  THE  DECEPTION  OF  INTELLIGENT  PEOPLE. 

we  cannot  prevent  our  friends  and  neighbors  from  holding  and  propa- 
gating beliefs,  views,  and  doctrines  which  from  the  stand-point  of  fact  and 
reason  may  be  inadmissible.  Many  of  the  questions  upon  which  there  is 
wide  difference  are  really  open  to  discussion,  and  where  there  is  doubt  all 
ought  to  keep  their  minds  open  to  conviction  if  evidence  should  be 
adduced,  but  many  assertions  which  are  commonly  and  frequently 
advanced  are  not  reasonable, — not  open  to  discussion.  The  assertion,  for 
example,  that  the  decillionth  of  a  grain  of  opium  produces  an  effect  on 
the  human  organism  is  one  of  these.  Many  years  ago  I  saw  in  a  hospital 
in  the  south  of  Europe  a  poor  woman  who  was  dying  of  cholera — was 
indeed  obviously  within  an  hour  or  two  of  death.  The  attending  physician 
examined  her  and  prescribed  "  Opium."  I  asked  him  what  quantity  of 
the  drug  he  had  ordered  the  patient  to  take,  and  after  some  calculation 
he  said,  "The  decillionth  of  a  grain."  Now,  I  shall  no  doubt  be  con- 
sidered by  some  who  prescribe  millionths  and  decillionths  a  very  prej- 
udiced person,  but  I  decline  to  discuss  with  a  man  who  believes,  or 
professes  to  believe,  either  that  he  was  actually  giving  this  quantity  of 
opium,  or  that  such  an  imaginary  amount  of  that  drug  would,  if  it  could 
be  introduced  into  the  body,  produce  any  effect  whatever  upon  the 
organism 

It  would  not  be  reasonable  to  expect  that  the  public  generally  should 
be  sufficiently  informed  concerning  medical  and  scientific  questions  to 
enable  them  to  form  a  judgment  as  to  the  relative  merits  of  different 
systems  of  medical  treatment,  any  more  than  we  can  expect  them  to 
investigate  such  questions  as  spiritualism  or  to  determine  the  nature  of, 
and  right  method  of  dealing  with,  certain  forms  of  contagious  disease. 
All  thoughtful  and  reasonable  professional  men  have,  however,  strong 
cause  of  complaint  when  they  find  that  persons  of  intelligence  holding 
positions  of  authority — law-makers,  ministers,  and  distinguished  political 
chiefs — so  express  themselves  as  to  lead  the  public  to  suppose  that  it  is 
as  reasonable  to  place  confidence  in  a  man  who  prescribes  the  millionth 
of  a  grain  of  charcoal  or  the  decillionth  of  a  grain  of  opium  as  in  one 
who  orders  ten  or  twenty  grains  of  the  first  or  a  tenth  of  a  grain  of  the 
last.* 

I  doubt  whether  anything  in  modern  times  is  upon  the  whole  more 
disgraceful  to  an  enlightened  community  than  the  spread  of  a  disease 
so  certainly  preventible  as  Small-Pox.  Only  think  of  the  absurdity  of 
having  to  provide,  at  enormous  expense,  accommodation  for  thousands 
of  people  suffering  from  and  spreading  this  loathsome  disease  when  every 
case  might  have  been  prevented  by  vaccination.  And  we  go  on  year 

*  It  is  remarkable  how  very  few  persons  seem  to  realize  the  tremendous  difference 
between  such  fractional  parts  as  hundredths,  and  thousandths,  and  millionths,  bill- 
iouths,  and  decillionths. 


CREDULITY  AND  IMPOSITION.  3! 

after  year  allowing  people  to  pay  fines  for  the  privilege  of  enjoying  the 
right  to  catch  Small-Pox  and  to  communicate  it  to  others. 

Intelligence  as  regards  one  department  of  knowledge  is  often  asso- 
ciated with  extraordinary  ignorance  and  credulity  concerning  others; 
nay,  the  same  individual  sometimes  manifests  the  extreme  of  scepticism 
as  regards  certain  things,  while  in  others  he  is  unsurpassed  for  his 
credulity.  You  will  find  some  persons  sceptical  concerning  demonstrable 
and  demonstrated  facts,  and  faithful  and  believing  in  respect  of  fictions  of 
the  imagination  and  dicta  of  the  most  nonsensical  character.  The  most 
profound  knowledge  of  logic,  mathematics,  law,  classics,  or  metaphysics 
will  not  protect  a  man  from  imposition  and  quackery  as  regards  the 
nature  and  management  of  the  ailments  of  his  body,  and  there  are  not  a 
few  persons  distinguished  for  great  intellectual  power  who  have  been 
duped  by  quacks,  while  they  altogether  mistrnsted  the  true  statements  of 
honest,  straightforward  medical  practitioners.  There  is  nothing  more 
extraordinary  than  the  trust  often  reposed  in  what  is  false,  and  the  doubt, 
disbelief,  and  suspicion  indicated  concerning  that  which  is  true. 

In  the  matter  of  medical  advice,  and  not  uncommonly  in  high 
quarters,  humbug  sometimes  rules  supreme.  Character,  experience, 
unremitting  work  often  go  for  nothing.  In  England  and  in  America 
there  is  nothing  more  wonderful  than  the  great  success  obtained  by 
persons  utterly  ignorant  of  their  calling.  There  still  lurks  much  belief 
in  mysterious  and  inexplicable  actions  as  regards  medicines  and  in,  the 
wonder- working  powers  of  some  who  prescribe  them.  This  it  is,  possibly, 
which  enables  the  self-praising,  vulgar  empiric  to  exert  a  favorable 
impression  upon  those  who  are  at  best  but  very  ill-informed  concerning  . 
matters  of  health  and  disease.  It  is  curious  how  some  even  of  our 
very  simplest  prescriptions  get  handed  about  from  one  to  another 
in  consequence  of  some  wonder-working  power  they  are  supposed  to 
possess,  which  would,  I  fear,  vanish  in  a  moment  if  only  they  were  trans- 
lated into  English.  Still  we  may  hope  that  the  time  is  not  far  distant 
when  we  may  order  Carbonate  of  soda,  Hydrochloric  acid,  and  such  like 
simple  medicines,  which  often  afford  the  greatest  relief,  without  envel- 
oping them  in  a  cloak  of  mystery.  People  would  often  be  much 
astonished  if  they  knew  what  cheap  and  common  drugs  they  some- 
times bought  at  extravagant  prices  in  various  highly-puffed  patent  medi- 
cines of  secret  composition,  not  a  few  of  which  simple  remedies  we  are 
prescribing  every  day. 

It  is  hardly  reasonable  to  expect  that  we  should  be  able  to  persuade 
people,  especially  those  who  are  well  off,  to  live  like  reasonable  creatures; 
but  those  who  are  completely  ignorant  of  medical  knowledge,  and  who 
come  to  us  for  advice  and  assistance,  go  a  little  too  far  when  they  suggest 
or  dictate  to  us  the  kind  of  advice  we  are  to  give,  the  medicines  we  are 
to  order,  and  the  methods  of  treatment  which  we  are  to  adopt,  we 


32  IMPOSTURE  AND  NONSENSE. 

having  been  studying  during  many  years  the  nature  and  causes  of 
disease,  while  they  are  utterly  ignorant  of  the  whole  matter.  And  yet 
this  is  no  imaginary  picture ;  there  are  people  who  know  nothing  of 
science,  and  who  have  never  seen  anything  of  sick  people,  who  neverthe- 
less talk  as  if  they  were  thoroughly  experienced  in  the  science  and 
practice  of  medicine.  Such  persons  sometimes  condemn  us  because 
we  decline  to  "consult"  with  men  who  practise  according  to  con- 
jectural principles  based  neither  on  experiment,  observation,  nor  experi- 
ence. Certain  rich,  inflnential,  and  fashionable  persons  having 
patronized  and  embraced  some  absurd  medical  conceits,  profess  to  be 
grievously  offended  with  some  practitioner,  who  perhaps  has  been  study- 
ing and  teaching  medicine  for  half  a  lifetime,  because  he  declines  to 
adopt  measures  which  the  patient  himself  desires  out  of  mere  caprice 
should  be  carried  out. 

It  has  been  my  lot  to  study,  on  more  than  one  occasion,  the  well- 
turned  phrases  and  persuasive  sentences  by  which  a  popular  prescriber  of 
decillionths,  brimful  of  tact,  managed  to  bring  conviction  to  the  minds 
of  people  of  intelligence,  and  at  the  same  time  to  impress  them 
with  his  profound  knowledge  and  intelligence,  though  all  the  time  he 
was  writing  nonsense,  and  probably  knew  that  he  was  doing  so.  But, 
as  is  well  known,  cleverly  stated  nonsense  often  hits  the  mark,  and 
will  continue  to  do  so  for  many  a  long  year.  Men  high  among  the 
most  intelligent  and  most  learned,  nay,  men  who  have  been  looked  up 
to  as  men  of  the  world,  have  often  been  humbugged  in  matters  medical, 
and  even  profound  lawyers  have  failed  to  distinguish  medical  nonsense 
from  medical  sense,  and  mere  sham  science  from  real  scientific  knowl- 
edge. Those  who  are  always  gauging  the  value  of  evidence,  and  devoting 
themselves  to  the  extraction  of  truth,  seem  to  be  specially  susceptible  to 
medical  and  scientific  imposition.  But  there  is  hardly  a  department  of 
human  endeavor  in  these  days  in  which  you  will  not  find  audacious 
humbugs  influencing  opinion,  and  gaining  for  a  time  notoriety  and 
renown  at  the  hands  of  their  dupes. 

But  if  we  raise  our  voice  ever  so  gently  against  nonsense  and 
imposture,  some  of  the  writers  belonging  to  the  organs  of  so-called 
public  opinion  hold  up  to  reprobation  what  they  denominate  the  pro- 
verbial jealousy,  the  intolerance,  the  illiberality,  and  the  narrow-minded- 
ness of  the  doctors.  The  comments  in  the  supposed  interests  of  the 
public  and  the  strictures  passed  upon  us  are  sometimes  most  comical, 
but  you  will  find  sometimes,  I  fear,  that  your  work  is  rendered 
very  difficult  in  consequence.  If  you  attend,  through  a  very  long 
and  serious  illness,  a  patient,  who,  from  the  badness  of  the  times,  is 
unable  to  afford  you  any  remuneration  for  your  services,  and  you  hear 
that  as  soon  as  he  was  able  to  get  about  he  placed  himself  under  the 
care  of  a  distinguished  quack,  who  found  it  necessary  to  see  him  every 


WANT  OF  CONFIDENCE   IN  US.  33 

day,  and  received  a  handsome  fee  each  time,  you  are  to  consider  your- 
selves fortunate  in  belonging  to  a  liberal  profession,  and  though  you 
receive  nothing  for  your  work,  you  are  not  to  feel  jealous  of  the  quack 
who  is  well  paid  perhaps  for  doing  nothing,  perhaps  for  the  mistakes  he 
has  made.  If,  after  having  ridden  over  hundreds  of  miles  of  ground  of 
the  roughest  country  in  the  roughest  weather  to  attend  the  sick  pool 
around  you,  finding  not  only  medicine  for  all,  but  food  and  medical 
comforts  for  not  a  few,  you  one  day  discover  that  the  only  people 
within  ten  miles  of  you  enjoying  an  income  of  more  than  a  hundred 
a-year  have,  out  of  the  purest  kindness,  invited  a  celebrated  homoeopath 
to  visit  them,  and  he,  also  out  of  kindness,  has  seen  and  prescribed  for 
a  number  of  your  patients  at  half  the  fee  he  usually  receives,  and  has 
been  paid  more  money  by  your  poor  patients  in  a  week  than  you  will 
receive  in  a  year,  you  are  to  feel  thankful  that  you  live  in  a  free  country, 
where  opportunity  is  afforded  to  all.  If,  after  having  served  the  offices 
of  House  Surgeon,  House  Physician,  and  many  minor  appointments  in 
a  public  Hospital,  and  qualified  with  honors,  the  wealthiest  of  your 
neighbors  gives  it  out  that  you  are  very  kind  to  the  poor,  and  that  the 
servants  are  well  satisfied  with  you,  while  he  and  the  members  of  his 
family,  when  there  is  anything  the  matter,  send  over  to for  a  dis- 
tinguished eclectic  doctor  of  philosophy  who  graduated  abroad,  and  is 
supposed  to  have  had  great  experience,  but  whose  early  history  and 
training  are  involved  in  obscurity,  patiently  submft.  If  he  neither  knows 
the  test  for  albumen,  nor  its  import  when  present  in  the  urine;  if  he 
discards  as  useless  physical  examination  of  the  chest ;  and  disapproves 
of  the  stethoscope,  microscope,  and  other  "medical  toys,"  because 
by  prolonged  inquiries  into  the  mysteries  of  the  magnetization  of  the 
solids  and  fluids  of  the  body  he,  as  he  says,  has  detected  molecular  anti- 
gyrations  of  a  most  important  character  in  the  component  particles  of 
the  brain  and  nerves, — and  if  by  the  administration  of  gyrating  "similars" 
in  the  shape  of  small  globules,  largely  composed  of  sugar  of  milk,  this 
celebrity  professes  to  be  able  to  combat  pathological  phenomena  before 
they  could  establish  disease,  do  not  be  indignant.  You  may  be 
expected  to  preserve  an  attitude  of  deferential  awe  or  respect  whenever 
the  distinguished  and  eminently  successful  authority  is  spoken  of. 
You  may  not  discover  his  name  on  the  medical  register,  and  you 
may  find  that  as  soon  as  any  patient  is  indiscreet  enough  to  become 
very  seriously  ill,  some  "ordinary"  medical  practitioner,  perhaps  your- 
self, is  requested  just  to  attend  as  "a  matter  of  form."  You  may 
possess  incontrovertible  evidence  that  the  distinguished  person  is  utterly 
ignorant  of  the  very  elements  of  medicine,  but  you  must  not  be  sur- 
prised to  find  out,  notwithstanding,  that  his  important  services  have  been 
judged  to  be  worth  m"»re  than  five  times  as  much  as  the  county  pays 
for  your  own  conferred  upon  hundreds  of  poor  people,  and  extending 

C 


34  PRINCIPLES  OF  CONDUCT. 

over  a  much  longer  period  of  time.  We  may,  no  doubt,  derive  some 
consolation  from  the  reflection  that  we  belong  to  a  truly  liberal  profession, 
and  do  not  practise  merely  for  the  purpose  of  receiving  pay.  You  may, 
perhaps,  think  it  hard  that  unqualified  and  only  partly  legally  qualified 
charlatans  are  not  prevented  by  law  from  humbugging  innocent  people, 
as  is  the  case  in  some  countries  which  have  not  reached  the  high  degree 
of  civilization  which  we  enjoy,  but  rather  you  should  feel  thankful  that 
the  Government  does  not  pass  laws  which  might  conduce  to  the  further 
impoverishment  and  degradation  of  legally  qualified  medical  men  who 
attend  the  poor  of  the  district  in  which  they  live.  No  doubt  many 
highly  influential  law-making  persons  agree  with  eclectics,  animal  mag- 
netizers,  hydro-,  homceo-,  and  other  "paths,"  in  the  opinion  that  it  is 
degrading  for  a  genius,  a  conjurer,  or  a  certain  cure  to  submit  to  the 
ordeal  of  examinations  on  elementary  anatomy,  physiology,  and  medi- 
cine conducted  by  unpractical  theorizers,  and  presided  over  by  the 
narrow-minded  supporters  of  "  medical  trades-unions  "  ! 

After  all,  it  must  be  conceded  that  the  most  popular  of  quacks 
seldom  enjoys  more  than  a  short-lived  reputation.  He  has  to  make 
hay  while  the  sun  shines,  for  he  may  soon  have  to  give  place  to  a  greater 
quack  than  himself,  and  pass  into  obscurity.  On  the  other  hand, 
although  we  may  in  every  way  receive  far  less  than  our  due,  we  belong 
to  a  body  rightly  proud  of  its  history  and  confident  as  to  its  future. 
Resting  on  science,  medicine  must  progress  as  knowledge  advances. 
As  information  spreads,  respect  for  real  work  will  increase.  The  regard 
for  the  medical  practitioner  will  be  higher  in  the  future  than  it  has  been 
in  the  past,  and  by  and  by  the  numbers  of  those  who  appreciate  our  work 
and  put  trust  in  us  will  include  as  many  as  the  most  enthusiastic  among 
us  could  desire. 

We  are,  as  I  have  remarked,  sometimes  placed  in  a  position  of  great 
difficulty,  and  much  perplexed  as  to  the  course  we  ought  to  take. 
Occasionally,  regard  for  the  honor  of  the  profession  would  seem  to 
require  a  course  of  action  which  might  not  coincide  with  the  interest  of 
the  patient  or  be  in  accordance  with  that  consideration  and  kindness 
which,  under  all  circumstances,  should  be  extended  to  the  sick  and 
suffering. 

If  we  carefully  bear  in  mind  that  the  credit  and  honor  of  us  all  are 
of  higher  consequence  than  individual  success,  or  personal  loss,  or 
even  injustice — if  we  explain  that  we  have  nothing  to  keep  secret,  no 
mysteries  to  protect  or  preserve — that  on  the  contrary  we  desire  that 
the  knowledge  we  possess  should  spread,  and  that  all  possible  means  of 
relief  and  all  methods  of  preventing  disease  should  be  widely  diffused  ; 
that  we  court  inquiry  into  the  principles  upon  which  our  methods  of 
investigation  and  treatment  are  based,  and  desire  that  our  reasonings 
thereupon  should  be  examined  and  criticised,  we  shall  seldom,  I  think, 


SLIGHT  AILMENTS  AND   OUT-PATIENTS.  35 

experience  difficulty  in  deciding  how  we  ought  to  act  in  almost  any  case 
that  may  arise.  We  must,  in  short,  endeavor. to  apt  for  the  advantage 
and  honor  of  the  profession  without  in  the  smallest  degree,  or  in  any 
way  sacrificing  the  interests  of  the  sick  person,  and  without  wounding 
the  feelings  of  the  patient  or  his  friends.  In  these,  and  in  all  other 
difficulties  we  encounter,  we  shall  act  upon  the  maxim  Fac  recte  nil 
time. 

Of  Studying  Slight  Ailments  in  the  Dispensary  Department  of 
the  Hospital.  —  Great  principles  as  regards  the  treatment  of  disease 
may,  without  doubt,  be  learned  and  taught,  and  the  influence  of  im- 
portant remedies  illustrated  in  the  case  of  slight  ailments  as  well  as  in 
grave  disorders.  The  circumstance  that  little  attention,  comparatively 
speaking,  has  been  paid  to  this  part  of  medicine  in  modern  systematic 
works,  makes  me  particularly  desirous  to  bring  it  under  your  notice. 

You  may  learn  a  good  deal  about  man's  slight  derangements  if  you 
study  in  the  dispensary  department  of  the  hospital,  or  in  public  dispen- 
saries, and  I  strongly  advise  you  to  take  advantage  of  the  opportunities 
that  may  offer.  Do  not  be  deterred  from  spending  time  in  this 
department,  although  you  may  hear  disparaging  observations  concerning 
out-patient  medical  work,  both  from  professional  and  non-professional 
people.  It  is  now  the  fashion  to  condemn  the  system  upon  which  the 
dispensary  department  of  most  of  our  hospitals  has  long  been  success- 
fully conducted.  To  those  unacquainted  with  the  facts,  there  seems 
much  that  is  plausible  in  the  objections  raised,  but  it  will  be  found 
that  the  desire,  on  the  part  of  some  enthusiasts  in  charity  organiza- 
tion, to  improve  the  out-patient  department  of  hospitals  is  supple- 
mented by  a  much  stronger  desire  to  do  everything  to  encourage  the 
so-called  self-supporting  dispensary  system,  based  on  the  hypothesis 
that  working-men  and  others  are  degraded  if  they  receive  relief  from 
their  sufferings  without  paying  something.  The  "  facts  "  and  the  value 
of  the  arguments  advanced  may  be  judged  by  the  oft-repeated  assertion 
that  a  fourth  of  the  population  of  London  receives  gratuitous  medical 
treatment. 

There  is  a  class  of  philanthropists  whose  dictum  it  is  that  every  one 
ought  to  pay  for  medical  advice,  and  that  if  he  cannot  pay  enough  to  re- 
munerate a  practitioner  he  should  combine  with  others  placed  in  a  similar 
position,  and  so  form  a  club  to  which  a  salaried  medical  officer  is 
appointed.  The  "self-supporting"  system  is,  however,  in  many 
instances,  not  a  reality,  while  any  one  who  knows  much  of  the  working 
classes,  knows  that  the  demand  for  medical  help  and  medical  comforts 
usually  comes  at  a  time  when  little  or  no  money  is  being  earned. 
Thousands  of  pounds  are  to  be  collected  for  starting  these  "self-sup- 
porting" dispensaries,  which,  therefore,  are  "self-supporting"  only  in 
name.  Charitable  persons  are  to  give  in  order  that  certain  members  of 


36  THE  POOR  AND  HOSPITALS. 

the  population  may  be  doctored  at  half  the  usual  cost,  or  less  than  that. 
I  have  seen  a  great  deal  of  the  poor  and  of  out-patient  hospital  practice, 
and  as  I  have  not  met  with  the  so-called  evils  of  the  system,  I  cannot 
advocate  the  proposed  remedies.  Many  of  the  energetic  legislators  in 
connection  with  medical  charity  seem  to  think  that  no  one  who  suffers 
from  a  pain  in  his  stomach  should  be  relieved  until  he  has  either  paid 
for  help,  or  has  proved  that  he  is  a  really  necessitous  and  impecunious 
person.  I  believe  that  if  some  of  the  new  suggestions  were  carried  out, 
the  profession  would  not  only  receive  less,  but  would  have  to  give  more 
advice  for  nothing  than  they  do  now. 

Up  to  this  time  the  Dispensary  departments  of  our  hospitals  have 
been  of  the  greatest  service  to  the  poor,  and  of  great  advantage  to  those 
who  are  studying  medicine.  It  is  there  we  learn  to  interpret  the  curious 
descriptions  given  by  people  in  so  many  different  ways  of  the  aches  and 
pains  theyexperience — there  we  learn  to  recognize  the  difference  between 
apparent  and  actual  suffering — there  we  are  taught  to  quickly  discern 
different  forms  of  disease,  and  to  acquire  that  ready  method  of  investi- 
gation which  is  so 'valuable  in  after  life.  Moreover,  some  of  the  hardest 
workers  among  us  prefer  to  give  their  services  out-and-out  rather  than 
receive  the  pittance  which  seems  to  be  considered  by  some  reformers  as 
payment  for  services  rendered, — and  pitied  and  possibly  despised  as  poor 
doctors  whose  services  are  valued  at  a  very  small  summer  annum,  and  to 
be  obtained  by  right  by  those  who  promise  to  pay  a  few  pence  per  week. 

Although  complaints  may  be  made  of  the  rate  at  which  people  are 
gratuitously  seen  and  dismissed,  the  out-patient  hospital  physician,  in 
fact,  seldom  misses  an  important  case  of  actual  disease,  while  of  his 
real  use  to  the  poor  there  can  be  no  question  whatever.  Slight  ailments 
are  prescribed  for  and  relieved,  while  serious  cases  of  disease  are  detected 
and  at  once  transferred  to  the  wards,  without  those  inquisitorial  investi- 
gations which  seem  to  form  a  very  important  factor  in  model  sick-poor 
relief  and"  centralization  and  general  organization.  It  is  doubtful  if,  by 
any  system  that  can  be  inaugurated,  a  poor  patient  will  be  more  quickly 
relieved  and  cared  for  than  by  the  one  which  has  been  gradually  built  up 
by  members  of  our  profession,  and  is  now  in  useful  operation  in  hun- 
dreds of  institutions.  To  teach  providence  to  all  classes  is  very  laud- 
able, but  there  is  no  good  reason  why  this  desirable  lesson  should  be 
taught  by  lowering  the  status  of  the  medical  practitioner.  We  must 
never  forget  that  our  work  is  to  relieve  suffering  as  promptly  and  as 
efficiently  as  possible,  and  it  is  on  all  grounds  better  that  we  should 
sometimes  give  our  services  altogether  than  accept  what  is  called 
remuneration  of  a  very  inadequate  character. 

The  Treatment  of  Slight  Ailments  conducted  on  the  same  Principles 
as  that  of  Serious  Diseases. — There  is,  lastly,  this  very  cogent  reason 
which  impels  me  to  direct  your  attention  thus  early  in  my  course  to  the 


Los  Ai,£efa  c 
REMEDIES  IN  SLIGHT  AILMENTS.  37 

consideration  of  slight  ailments.  It  will  be  found  that  many  of  the 
principles  upon  which  the  treatment  of  trivial  derangements  is  con- 
ducted obtain  in  the  management  of  graver  maladies.  This  is  a  matter  of 
the  highest  practical  importance,  and  in  not  a  few  instances  you  will 
find  that  attention  to  the  relief  of  slight  ailments  will  afford  you  great 
assistance  in  determining  the  proper  course  to  pursue  in  the  treatment 
of  very  serious  forms  of  acute  disease.  For  example,  I  shall  be  able  to 
show  you  that  the  treatment  of  a  grave  disorder  like  acute  rheumatism 
is  based  upon  facts  and  reasoning  which  apply  equally  to  slight  affec- 
tions of  a  rheumatic  nature.  Fevers  and  inflammations  of  the  very 
slightest  character  afford  lessons  of  the  greatest  value  concerning  the 
management  of  every  disease  of  that  class. 

By  observing  carefully  the  action  of  remedies  in  slight  ailments,  we 
may  gain  knowledge  which  will  be  of  the  greatest  use  to  us,  and  espe- 
cially in  the  treatment  of  slight  derangements  of  our  own  health  may  we 
hope  to  gain  very  definite  information  concerning  the  precise  action  of 
some  of  the  most  important  of  the  medicines  we  employ.  I  am  sure 
that  any  one  who  has  experienced  the  change  in  his  sensations  which 
occurs  after  taking  a  few  doses  of  ammonia  in  the  course  of  an  ordinary 
cold,  or  has  noticed  the  pleasant  alteration  which  occurs  during  an 
attack  of  quinsy  as  soon  as  diuretic  and  sudorific  remedies  have  com- 
menced to  act,  or  is  practically  acquainted  with  the  relief  afforded  in 
sick  headache  by  a  grain  or  two  of  gray  powder  or  calomel,  will  be  quite 
convinced  of  the  usefulness  of  medicine,  will  not  altogether  despise  the 
views  and  practice  of  forty  years  ago,  or  feel  reduced  to  advocate  the 
administration  of  colored  water  to  his  suffering  contemporaries,  or  wilf 
propose  to  leave  a  number  of  cases  of  different  forms  of  disease  without 
any  medical  treatment  whatever,  in  order  that  he  may  observe  what  has 
been  naively  termed  the  "natural  history  of  disease,"  the  patient,  of 
course,  not  wishing  to  complicate  the  interesting  inquiry  by  desiring  the 
relief  of  his  suffering  and  quick  convalescence. 

There  are  many  valuable  points  connected  with  prescribing,  which 
are  of  the  utmost  importance,  and  which  are  to  be  learned  from  the 
practitioner  who  is  well  acquainted  with  the  management  of  slight 
ailments.  I  have  often  heard  the  remark  that  our  predecessors  knew 
more  about  the  treatment  of  disease  than  we  of  this  generation  do. 
There  is  some  truth  in  this ;  and  I  am  sure  that  many  old  practitioners 
now  living  are  more  successful  in  relieving  the  aches  and  pains  of  their 
patients  than  some  of  the  young  ones,  who  may,  nevertheless,  have  a 
far  more  intimate  knowledge  of  the  diagnosis  of  obscure  forms  of 
disease  and  of  the  minute  pathological  changes  which  have  damaged 
tissues  and  organs.  Those  of  you  who  have  worked  under  country 
practitioners  enjoy  a  great  advantage  in  this  respect,  and  will  be  aware 
of  many  things  connected  with  the  art  of  prescribing  for  symptoms,  of 
4 


38  MICROSCOPICAL   INVESTIGATION. 

which,  even  men  who  have  highly  distinguished  themselves  in  our 
medical  classes  and  medical  examinations,  may  be  in  total  ignorance. 
Nor  do  I  see  how  this  very  desirable  practical  information  can  be 
gained  in  any  better  way.  I  may  try  to  convey  to  you  some  of  the 
wrinkles  I  have  learned  from  my  own  masters,  but  shall  only  very  imper- 
fectly succeed.  To  offer  remarks  on  the  details  of  treatment  when 
prescribing  for  the  sick  person  in  the  country  surgery  is  advantageous, 
but  to  give  in  lectures  or  at  the  bedside  at  the  hospital  detailed  in- 
formation as  to  the  combination  of  remedies  in  pills  and  mixtures,  and 
a  number  of  things  of  considerable  importance  practically,  would  be 
tedious,  and  would  take  so  long  a  time,  that  I  could  not  expect  a  class 
to  listen  to  such  matters  with  attention.  I  shall,  therefore,  only  venture 
to  trouble  you  now  and  then  with  details  as  regards  prescribing,  but  it  will 
be  well  for  you  to  take  note  of  prescriptions,  which  I  have  frequently 
found  of  great  value  in  the  management  of  cases  of  deranged  health. 

Importance  of  Knowledge  derived  from  Microscopical  Investigation. 
— In  all  healthy  changes,  in  all  derangements,  in  all  forms  of  disease, 
thousands  of  very  minute  particles,  each  of  complex  arrangement  and 
composition,  are  implicated.  It  is  by  the  united  action  of  multitudes  of 
these  that  the  broad  phenomena  evident  to  us  as  healthy  actions, 
derangements,  morbid  changes  are  occasioned.  Do  not,  therefore,  cast 
a  slur  on  the  consideration  of  minute  details,  do  not  neglect  the  facts 
arrived  at  by  microscopical  investigation.  Rather,  on  the  other  hand, 
try  to  acquire  the  power  of  seeing  in  imagination  the  very  particles 
which  are  involved,  and  of  contemplating  the  phenomena  proceeding 
in  connection  with  them. 

Bear  in  mind  that  around  and  in  the  interstices  between  the  molecules 
of  matter  composing  each  elementary  part  of  a  living  organism  changes  are 
constantly  taking  place.  Remember  that  of  the  matter  of  the  elementary 
part  the  bioplasm  only  lives  and  is  the  seat  of  vital  action.  The  formed 
material  which  results  from  the  death  of  particles  of  the  bioplasm  is  the 
seat  of  physical  and  chemical  changes  only. 

These  elementary  parts  are  so  small  that  a  thousand  thousand  of 
them  might  not  occupy  more  than  a  cubic  inch.  Each  of  them  during 
.life  is  the  seat  of  incessant  change.  Towards  the  bioplasm  of  each, 
streams  of  fluid,  holding  various  substances  in  solution,  continually  tend, 
and,  having  reached  it,  part  with  certain  constituents,  there  to  be  made 
into  living  matter,  while  the  fluid,  deprived  of  these,  again  traverses  the 
formed  material,  and  is  taken  up  by  the  blood  or  is  otherwise  disposed 
of.  Thus  the  formed  material  or  tissue  of  every  organ  of  the  body  is 
being  constantly  bathed  by  fresh  portions  of  fluid,  bringing  and  taking 
away,  dissolved  in  it,  things  required  for  use  or  things  which  must  be  got 
rid  of.  This  continual  movement  of  fluid  characterizes  everything  living 
from  the  lowest  to  the  highest.  In  every  form  of  plant  and  animal  it  is 


INTER-MOLECULAR   CIRCULATION.  39 

present  and  essential.  When  the  flow  is  impeded  derangement  results, 
and  degeneration  and  decay  may  commence;  when  it  stops,  death  takes 
place,  and  the  portion  of  tissue  thus  losing  the  preservative  influence 
exerted  by  the  never-ceasing  currents  of  fresh  portions  of  fluid  through 
its  most  minute  interstices,  undergoes  chemical  decomposition,  just  as  a 
portion  of  tissue  taken  from  a  dead  animal  would  do  if  kept  artificially 
at  a  temperature  of  100°.  The  deleterious  gases  and  other  poisonous 
substances  formed,  if  there  is  no  vent  by  which  they  can  escape  alto- 
gether, may  pass  into  the  blood  and  contaminate  or  actually  poison 
every  drop  of  the  nutrient  fluid,  or  may,  by  transudation  into  adjacent 
tissue,  destroy  it  by  causing  the  death  of  its  living  matter.  In  this  way 
a  large  portion  of  tissue  may  soon  be  involved,  and  the  death  of  the 
individual  must  shortly  follow. 

There  is,  in  fact,  a  constant  circulation  —  a  constant  interchange  of 
gases  and  certain  solid  matters  dissolved  in  fluid,  some  of  which  are 
appropriated  as  nutrient  material,  while  others  are  removed  as  products 
of  decay.  This  never-ceasing  circulation  goes  on  around  and  amongst 
the  smallest  particles  of  tissues  and  organs.  Slow-moving  tiny  streamlets 
bathe  the  very  molecules  of  the  cells  or  elementary  parts,  and  thus 
minister  not  only  to  the  growth  and  increase  of  the  bioplasm,  but  by  aid 
of  these  currents  alone  can  the  formed  material  of  the  different  tissues 
be  preserved  in  a  healthy  and  active  state. 

What  may  be  correctly  termed  an  active  inter-molecular  circulation  is 
one  essential  condition  of  a  healthy  state  of  tissues,  and  it  will  be  well 
for  us  to  occupy  a  few  minutes'  time  in  its  consideration. 

In  plants  the  inter-molecular  circulation  is  equally  essential,  and  the 
constant  removal  of  fluid  consequent  upon  evaporation  from  the  sur- 
face of  the  leaves  is  one  of  .the  most  important  of  the  operations  con- 
cerned in  establishing  and  maintaining  a  very  free  circulation  of  fluid 
around  and  in  and  out  of  every  living  cell  of  the  plant.  Even  in  the 
lowest,  simplest,  and  most  minute  of  living  forms  inter-molecular  circula- 
tion begins  with  existence  and  never  ceases  until  death  takes  place.  It 
is  one  of  the  phenomena  constant  in  and  characteristic  of  every  form 
of  life,  but  it  is  peculiar  to  living  things.  There  is  nothing  like  it  in 
any  non-living  matter. 

The  importance  of  the  continual  flow  of  fresh  particles  of  fluid 
through  all  the  formed  material  or  tissue  of  every  part  of  the  organism 
cannot  be  exaggerated.  The  rate  of  flow  changes  from  time  to  time,  and 
though  it  may  sometimes  take  place  very  slowly,  the  movement  never 
stops  as  long  as  life  lasts,  without  derangement,  damage,  or  destruction  of 
the  portion  of  tissue  involved.  You  must  try  to  picture  to  yourselves  these 
never-ceasing  movements  of  fluid  simultaneously  proceeding  in  every  ele- 
mentary part  of  every  tissue  of  the  organism,  though  it  may  be  less  than 
the  thousandth  of  an  inch  in  diameter.  It  is  obvious  that  the  activity  of 


40  MOLECULAR   CIRCULATION  OF  FLUID. 

these  movements  will  in  some  measure  depend  upon  the  quantity  of  ' 
fluid  taken  up  by  the  blood.  If  the  nutrient  fluid  is  habitually  deficient 
in  water,  more  especially  if  it  be  surcharged  with  only  slightly  soluble 
materials,  there  will  be  slow  molecular  circulation  and  a  tendency  to  the 
deposition  of  some  of  these  slightly  soluble  matters  in  tissues  where  the 
circulation  is  slowest.  It  is  in  this  way  that  urates  are  deposited  in 
fibrous  tissues  where  ordinarily  the  circulation  is  slow,  in  cases  of  gout. 
Substances  may  be  introduced  from  time  to  time  into  the  blood  which 
have  the  property  of  exerting  a  solvent  action  on  these  slightly  soluble 
compounds.  In  this  way  their  deposition  maybe  prevented,  or,  if  depos- 
ited, their  resolution  and  reintroduction  into  the  blood,  and  at  last  their 
excretion  from  the  body,  maybe  effected.  The  knowledge  of  the  phenom- 
ena proceeding  in  the  interstices  of  tissues  enables  us  to  understand  pre- 
cisely how  many  of  our  remedies  act.  The  careful  consideration  of  such 
minute  changes  may  enable  us  to  suggest  methods  of  treatment  in 
various  cases  of  great  importance  and  value.  We  may  act  upon  the 
formed  material  itself,  rendering  it  more  soft  or  more  firm,  help  or  inter- 
fere with  the  deposition  pf  insoluble  matters  in  its  substance,  influence 
the  growth  of  bioplasm,  assist  the  removal  of  products  of  its  death,  and 
bring  about  many  changes  of  the  greatest  consequence  in  treatment. 
Many  of  the  diseases  we  have  to  diagnose  and  treat  are  due  to  a  dis- 
turbed state  of  this  inter-molecular  circulation,  and  not  a  few  of  the 
most  serious  morbid  changes  result  from  diminished  activity  of  the  flow. 
Thus  many  matters  which  ought  to  be  washed  away  accumulate  in  the 
interstices  of  the  tissues  and  impede  their  action. 

When  we  can  restore  this  molecular  circulation  to  its  normal  state 
derangements  of  various  kinds  are  at  once  relieved,  and  in  treating  many 
forms  of  established  disease  our  principal  object  is  to  increase  the  activity 
of  the  inter-molecular  currents  in  the  interstices  of  the  tissues  involved. 
This  object  may  be  fulfilled  in  several  ways.  In  many  cases  free  perspi- 
ration and  indraughts  of  water  will  effect  it ;  sometimes  the  administra- 
tion of  frequently  repeated  doses  of  alkali  promotes  increased  activity 
of  the  inter-molecular  circulation,  and  assists  the  solution  of  imper- 
fectly soluble  matters  which  have  been  deposited,  or  are  in  course  of 
deposition. 

Looking  from  the  point  of  view  I  have  indicated,  it  will  be  well  to 
consider,  for  example,  what  is  the  precise  action  of  quinine  when  it  cures 
in  a  few  hours  certain  forms  of  obstinate  lumbar  pain.  What  happens 
when  local  thickening  of  the  subcutaneous  areolar  tissue  and  inflamma- 
tion of  the  sebaceous  glands,  that  may  have  lasted  for  months,  subsides 
in  a  fortnight  or  less  under  the  influence  of  biniodide  or  other  prepara- 
tion of  mercury. 

In  cases  in  which  too  much  nutrient  material  has  been  day  by  day 
introduced  into  the  blood  for  considerable  periods  of  time,  slow  circula- 


OF  THE    TONGUE.  41 

tion  or  stagnation  of  some  of  the  molecular  currents  in  various  tissues 
and  organs  of  the  body  will  occur.  Partial  starvation,  or  at  any  rate  a 
very  moderate  diet  for  several  weeks,  will  again  promote  the  flow.  Free 
perspiration  will  have  the  same  effect.  The  inhibition  daily  of  several 
tumblers  of  water  will,  by  favoring  the  transudation  of  fluid  from  the 
blood,  also  benefit  the  patient  by  washing  out  the  tissues  in  their  inter- 
stices, and  interfering  with  the  deposition  of  imperfectly  soluble  matters. 
Water  containing  alkalies  or  salts  of  vegetable  acids,  particularly  the 
citrates  and  tartrates,  will,  by  exciting  free  action  of  the  skin  and 
kidneys,  also  help  to  re-establish  currents  in  the  several  tissues  and 
organs  in  which  the  molecular  circulation  has  become  unduly  slow  or 
has  even  ceased. 

Further,  when  we  consider  the  close  proximity  of  the  nerve-fibres 
distributed  to  the  capillaries  to  the  very  thin  walls  of  these  tubes,  we  shall 
not  feel  surprised  that  nerve  changes  are  among  the  prominent  and  con- 
stant phenomena  of  disturbed  molecular  circulation.  Any  change  occur- 
ring in  the  composition  of  the  blood,  leading  to  a  diminished  tendency 
on  the  part  of  the  fluid  constituents  to  permeate  the  vascular  walls,  must 
produce  an  effect  upon  the  nerve-fibres  just  outside  the  capillary  vessels. 
If  the  capillary  vessels  are  over-distended  or  insufficiently  filled  with 
blood,  these  nerve-fibres  are  disturbed  and  will  transmit  impressions  to 
the  nerve-centre,  which  may  react  upon  the  nerves  distributed  to  the 
muscular  fibres  of  the  small  arteries,  resulting  in  dilatation  or  contrac- 
tion, and  may  cause  a  more  general  and  more  widely  distributed  nervous 
disturbance.  But  this  part  of  the  question  will  be  more  conveniently 
discussed  when  we  have  to  consider  the  vascular  phenomena  of  Inflam- 
mation and  Fever. 

OF   THE   TONGUE   IN   HEALTH   AND    IN   SLIGHT   AILMENTS. 

I  shall  in  the  first  place  speak  of  the  characters  of  the  tongue.  Few 
things  it  used  to  be  supposed  were  of  greater  consequence  than  the  recog- 
nition of  the  varied  character  which  the  dorsal  surface  of  the  tongue 
assumes  in  various  cases  of  actual  disease,  and  of  slight  derangements  of 
health. 

That  the  importance  of  the  characters  of  the  tongue  as  an  indica- 
tion of  internal  disease  has  been  exaggerated  by  some  physicians  is 
undoubtedly  true,  but  that  it  is  altogether  useless  as  an  indication  is 
certainly  an  incorrect  inference.  Any  one  who  is  at  the  pains  to  notice 
the  alterations  in  his  own  tongue  under  varying  conditions  of  health  will 
convince  himself  that  there  is  something  to  be  gained  by  noting  the 
changes  of  the  tongue  in  disease.  If  you  are  to  form  a  correct  estimate 
of  the  value  of  the  changes  in  the  characters  of  the  tongue,  you  must  be 
well  acquainted  with  the  appearance  of  the  surface  of  the  healthy  organ 
and  .with  the  exact  nature  of  the  structures  which  exist  upon  its  dorsal 
4* 


42  CHARACTERS  OF  TONGUE. 

surface.  Now,  I  dare  say  that  few  among  you  have  had  the  curiosity  to 
examine  the  back  of  the  tongue,  and  see  what  is  to  be  discovered  there 
by  microscopical  examination. 

If  you  scrape  off  a  small  piece  of  the  soft  matter  from  the  surface  of 
the  dorsum  of  the  tongue,  place  it  on  a  glass  slide,  and,  after  adding  a 
drop  of  water,  cover  it  with  a  piece  of  thin  glass,  and  examine  it  under 
a  quarter  of  an  inch  object-glass,  you  will  find,  though  the  tongue  be  in 
a  perfectly  healthy  state,  a  great  many  objects  of  interest,  of  which  I 
shall  have  to  speak  presently. 

I  dare  say  that  many  who  tell  patients  to  put  out  their  tongues  some- 
times do  it  as  a  matter  of  routine.  I  have  known  a  rather  absent 
doctor  tell  the  patient  to  put  out  his  tongue  several  times  in  the  course 
of  a  few  minutes'  medical  conversation.  Patients  are  sometimes  a  little 
prosy,  and  if  there  is  not  much  the  matter  with  them,  you  may  not 
attend  as  diligently  as  you  ought  to  do.  You  lose  the  thread  of  the 
discourse,  and  while  your  wits  are  wandering  you  may  cry  out  quite 
unconsciously,  almost  as  if  your  command  was  the  result  of  some  reflex 
and  habitual  action,  "  Put  out  your  tongue,"  although  the  organ  has  been 
already  more  than  once  displayed  for  your  examination. 

General  Characters  of  the  Surface. — The  character  of  the  tongue 
undoubtedly  is  very  much  influenced  by  the  state  of  the  stomach.  The 
mucous  membrane  which  lines  every  part  of  the  alimentary  canal  is,  as 
you  know,  continuous  with  that  which  lines  the  mouth  and  covers  the 
tongue.  Whenever  there  is  a  little  gastric  disturbance  the  tongue  usually 
participates  in  the  change.  The  relation  between  the  two  phenomena  is, 
however,  a  complex  one,  and  not  very  easily  explained.  Of  the  fact,  in 
very  many  cases,  there  is  no  doubt,  as  many  may  easily  prove  by  obser- 
vations upon  themselves. 

The  appearance  of  the  tongue,  as  I  shall  explain  more  in  detail 
further  on,  is  also  in  some  measure  affected  by  the  state  of  the  circula- 
tion, by  the  character  of  the  blood  itself,  as  well  as  by  the  rate  at  which 
the  epithelium  (tm,  upon,  and  rtfl^ut,  to  place)  on  its  surface  grows, 
arrives  at  maturity,  and  decays  and  falls  off.  Sometimes  the  epithelial 
cells  remain  intimately  adherent  to  the  tissue  beneath  upon  which  they 
are  placed,  and  from  which  they  seem  to  grow.  The  epithelium,  or 
rather  a  layer  of  it,  is  frequently  very  easily  detached,  but  sometimes  it 
adheres  very  firmly.  If  the  epithelium  on  the  dorsum  of  the  tongue  is 
very  thick  and  adherent,  the  tongue  looks  pale,  and  perhaps  white.  On 
the  other  hand,  if  the  epithelial  layer  is  very  thin  the  tongue  is  red. 

If  you  look  at  the  under  surface  and  sides  of  the  tongue  in  the 
looking-glass,  you  will  observe  that  these  parts  have  a  deep  red  appear- 
ance. The  epithelium  upon  the  sides,  and  the  deep  aspect  of  the  tongue, 
consists  of  a  layer  so  thin  that  the  color  of  the  blood  is  seen  through 
the  epithelial  tissue.  The  degree  of  redness  varies  according  to  the 


EPITHELIAL    COVERING    OF   TONGUE.  43 

distention  of  the  vessels,  and  depends  upon  changes  in  vascular  disten- 
tion  like  those  which  determine  the  redness  or  pallor  of  the  skin.  In 
blushing,  the  small  vessels  of  the  skin  of  the  cheeks  are  suddenly 
distended  in  consequence  of  an  inrush  of  blood  permitted  by  the  sudden 
yielding  and  dilatation  of  the  little  arteries  continuous  with  them,  and 
the  same  phenomenon  under  certain  circumstances  occurs  in  the  vessels 
of  the  tongue. 

The  Dorsum  of  the  Tongue. — On  the  dorsal  surface  of  the  tongue 
generally,  the  epithelium  (f*t,  upon,  and  n%u,  to  place)  is  arranged  to 
form  a  layer  of  considerable  thickness,  so  that  in  many  places  the  red 
color  of  the  blood  is  not  seen.  In  health  the  general  color  of  the 
dorsal  surface  inclines  to  pale  red,  but  in  certain  forms  of  disease  it 
becomes  of  a  bright  red  color,  almost  like  raw  beef,  and  it  is  in  con- 
sequence sometimes  spoken  of  as  "beefy."  This  seemingly  raw  con- 
dition depends  partly  upon  the  desquamation  and  falling  off  of  a  good 
deal  of  epithelium,  so  that  the  layer  covering  the  subjacent  structures 
is  much  reduced  in  thickness,  and  partly  upon  the  capillaries  being  dis- 
tended with  blood.  You  can  see  the  deep  red  color  of  the  blood 
through  the  epithelial  layer,  and  the  tongue  looks  raw.  The  mucous 
membrane  of  the  stomach  and  of  other  parts  of  the  intestinal  canal 
participates  in  this  change.  There  is  desquamation  of  the  epithelium 
and  undue  turgescence  of  the  vessels  beneath. 

On  the  Fungifonn  and  Filiform  Papillae,  and  of  their  Epithelial 
Covering. — In  health  there  are  to  be  seen  here  and  there  over  the 
dorsal  surface  little  spots,  which  are  of  a  bright  red  color.  Upon 
more  careful  examination,  it  will  be  found  that  the  red  spots  are  really 
small  papillae  with  a  constricted  neck,  in  shape  resembling  that  of  a 
mushroom,  and  known  as  the  Fungiform  (fungus)  Papilla.  The 
epithelium  investment  of  the  fungi  form  papillae  is  extremely  thin,  and 
the  blood-vessels  and  terminal  nerve  networks  lie  just  beneath.  The 
papillae  in  question  always  appear  red,  and  can  therefore  be  easily 
detected  here  and  there  amongst  the  filiform  or  conical  papillae  which 
are  more  uniformly  spread  over  the  dorsal  surface  of  the  tongue. 

The  epithelium  covering  the  surface  of  the  filiform  papillae  is  so 
thick  that  we  cannot  suppose  sapid  substances  could  quickly  pass 
through  it,  or  between  the  edges  of  the  overlapping  cells,  and  come  in 
contact  with  the  nerves  beneath.  These  filiform  {filum,  a  thread,  and 
forma,  likeness)  papillae  have  probably  nothing  to  do  with  the  sense  of 
taste,  but  are  important  organs  of  touch,  much  concerned,  it  may  be,  in 
the  process  of  placing  the  food  in  the  proper  position  for  mastication 
and  deglutition.  It  is  the  fungiform  papillae  and  the  soft  red  mucous 
membrane  at  the  sides  and  back  of  the  tongue,  and  that  of  the  palate 
and  fauces,  which  are  concerned  in  taste. 

As  regards  the  color  of  the  tongue,  it  may  be  remarked,  generally, 


44  EPITHELIAL    CELLS    OF  TONGUE. 

that  if  the  epithelial  layer  on  the  organ  is  thin,  the  tongue  will  be  red ; 
if  very  thick,  it  will  be  white ;  if  rather  dry,  of  a  dull  brown  or  dark 
brown  color;  and  if  there  is  an  abundant  accumulation  of  soft  and 
moist  epithelium  upon  its  surface,  of  a  very  opaque  dirty  white. 

Epithelial  Hair-like  Processes  of  the  Filiform  Papilla. — In  the  cen- 
tral part  of  the  dorsum  of  the  tongue  the  epithelial  sheaths  of  the  filiform 
papillae  are  very  long,  and  indeed  form  elongated  thread-like  filaments, 
closely  resembling  hairs  in  structure. .  You  may  snip  off  a  few  of  these 
hair-like  bodies  from  your  own  tongue,  or  scrape  portions  of  them  from 
the  central  part  of  the  back  of  the  surface  with  a  knife.  The  specimen 
is  then  to  be  placed  in  a  watch-glass  in  a  little  weak  glycerine.  After  the 
processes  have  soaked  for  a  time  they  may  be  placed  on  the  glass  slide, 
covered  in  the  usual  way  with  thin  glass,  and  examined  under  the  micro- 
scope, first  under  an  inch  power,  and  then  under  a  quarter  of  an  inch 
object-glass.  You  will  find  these  long  hair-like  processes  are  composed 
of  layers  of  scaly  epithelium  imbricated  and  superimposed  one  upon  the 
other.  The  longest  of  the  epithelial  filaments  project  from  the  dorsal 
surface  of  the  tongue,  perhaps,  for  more  than  the  twentieth  part  of  an 
inch.  Small  particles  of  food  often  become  entangled  amongst  these 
epithelial  extensions  of  the  filiform  papillse.  If  you  scrape  the  central 
part  of  the  back  of  the  tongue  a  short  time  after  you  have  taken  a 
meal,  and  examine  the  matter  as  just  described,  you  will  almost  in- 
variably find  a  number  of  oil  globules,  and  very  frequently  starch 
globules,  portions  of  muscular  fibres,  and  other  things,  according  to  the 
nature  of  the  last  food  taken. 

Of  the  Epithelial  Cells. — The  layer  on  all  the  papillae  of  the  tongue 
varies  in  thickness  from  time  to  time.  The  several  epithelial  cells  com- 
posing the  layer  necessarily  differ  in  age.  The  oldest  of  these  cells  are 
those  which  are  outermost,  or  situated  at  the  greatest  distance  from  the 
surface  on  which  they  grow,  and  the  youngest  are  those  which  are 
nearest  the  vessels.  Passing  outwards  we  meet  with  cells  gradually 
advancing  in  age.  The  oldest  are  constantly  decaying  and  falling  off. 
These  mix.  with  the  food,  and,  no  doubt,  during  every  meal  we  swallow 
them  in  thousands.  But  the  old  epithelial  cells  upon  the  tongue  and 
mucous  membrane  of  the  mouth  undergo  other  changes,  with  the 
general  nature  of  which  it  is  important  that  you  should  be  acquainted. 
The  changes  in  the  epithelium  should  therefore  be  carefully  studied  as 
opportunities  of  making  the  examination  occur. 

Of  Fungi  and  Low  Organisms  in  and  amongst  the  Epithelium  of 
the  Tongue  and  Mouth. — If,  then,  you  look  at  the  old  epithelial  cells 
detached  from  the  mucous  membrane  of  the  mouth,  from  the  inside  of 
the  check  or  the  tongue,  under  high  magnifying  powers  (from  three  to 
twelve  hundred  diameters),  you  will  find  that  the  cells  contain  a  number 
of  very  minute  spherical  or  oval  particles,  while  multitudes  of  very 


OF  FUNGI  AND  LOW  ORGANISMS.  45 

delicate  filaments  are  often  seen  amongst  them.  ("  Microscope  in 
Medicine,"  pi.  XXXVIII. ,  fig.  i,  p.  272.)  Now  these  minute  spherical 
and  oval  particles,  situated  in  the  formed  material  of  the  cell,  and  most 
numerous  at  its  outer,  that  is,  in  its  oldest  part,  are  very  low  and  simple 
organisms  in  an  early  phase  of  development.  They  have  been  called 
micrococci  (/uxpoy,  little,  and  xoxxoj,  a  grain),  and  have  received  other 
names.  In  this  state  they  have  not  reached  their  full  development. 
They  are  the  living  germs  of  organisms  which  exhibit  different 
characters  in  their  fully  developed  state.  Each  is  capable  of  producing 
millions  of  descendants  in  a  few  hours.  Some  of  them,  probably,  under 
certain  circumstances,  become  elongated,  and  evolve  bacteria  of  various 
forms;  others  may  form  the  long  thread  which  used  to  be  called 
Leptothrix  buccalis.  ("  Microscope  in  Medicine,"  pi.  LXXXL,  p.  492.) 
Some,  perhaps,  m^y  be  the  germs  of  Oidium  albicans  and  other  fungi. 
It  is,  probable,  indeed,  that  many  different  species  of  fungi  may  be 
developed  from  the  spherical  or  oval  germ-particles,  existing  in  con- 
nection with  the  older  epithelial  cells  on  the  surface  of  the,  mucous 
membrane  of  the  mouth.  The  germ-particles  themselves,  although  they 
closely  resemble  one  another  in  appearance,  may  have  been  derived 
from  different  species  of  organism.  The  various  species  of  germs  grow 
and  multiply  under  different  circumstances.  The  growth  and  multipli- 
cation of  such  minute  organisms  has  much  to  do  with  the  appearance 
which  the  tongue  presents  in  the  same  person  at  different  times,  as  well 
as  its  character  in  different  forms  of  derangement  and  disease. 

It  has  been  stated  by  more  than  one  observer  that  Sarcina  ventricull 
is  often  present  in  the  fur  of  the  tongue,  but  I  have  never  found  it  in 
this  situation,  though  I  have  examined  the  fur  in  very  many  cases 
during  the  past  thirty  years.  In  cases  in  which  sarcinse  were  found  in 
the  stomach,  I  did  not  find  them  on  the  tongue  or  in  other  situations. 
I  am  afraid  that  many  mistakes  have  been  made  with  regard  to  the 
identification  of  Sarcina  ventriculi. 

Old  epithelial  cells,  like  other  old  and  formed  tissue  or  other  dead 
organic  animal  or  vegetable  matter,  are  very  soon  invaded  by  the  germs 
of  low  vegetable  organisms,  always  very  numerous  in  their  vicinity, 
which  grow  at  their  expense  and  live  upon  their  substance.  Not  only 
on  the  surface  of  the  cells,  but  in  their  substance,  the  fungus  germs  are 
found,  and  frequently  project  from  them,  forming  little  collections, 
which  may  be  detached  from  time  to  time. 

Amongst  the  hair-like  epithelial  processes  projecting  from  the  free 
extremities  of  the  filiform  papillae,  are  often  found  masses  which  have  a 
granular  appearance  under  low  magnifying  powers.  When  examined 
under  objectives  magnifying  more  than  three  hundred  diameters,  these 
masses  will  be  found  to  consist  of  millions  of  spherical  and  oval  fungi 
or  micrococci,  grouped  together,  each  little  mass  of  bioplasm  being 


46  BACTERIA   AND  DISINTEGRATION. 

surrounded  by,  and  separated  from,  its  neighbors  by  clear  structureless 
material,  which  probably  has  been  formed  by  it. 

Amongst  the  epithelial  cells  in  every  part  of  the  mouth  you  will 
often  find  some  very  long  extremely  delicate  filaments,  which,  if  ex- 
amined under  high  powers,  will  be  found  to  exhibit  a  number  of  trans- 
verse markings.  These  grow  and  freely  multiply  in  the  fluids  of  the 
mouth  at  the  usual  temperature  of  that  cavity.  Many  are  found 
between  the  teeth,  and  in  the  tartar  you  will  meet  with  numbers  of 
vegetable  organisms.  Indeed,  it  is  probable  that  the  deposition  of  the 
tartar  is  intimately  connected  with  changes  occasioned  by  the  living 
vegetable  organisms  in  question,  which  belong  to  the  genus  Leptothrix. 
("Microscope  in  Medicine,"  pi.  LXXXL,  fig.  3,  p.  92.)  Many  of  the 
filaments,  long  and  short,  exhibit  peculiar  movements,  some  vibrating 
to  and  fro,  others  taking  a  spiral  course. 

In  many  cases  you  will  find  whole  forests  of  vegetable  organisms 
consisting  of  many  different  species,  and  of  the  same  species  at  different 
periods  of  growth,  upon  the  dorsal  surface  of  the  tongue.  These 
increase  in  number  in  cases  of  derangement  of  the  digestive  organs,  and 
in  many  forms  of  disease. 

The  growth  and  multiplication  of  these  low  organisms  at  the  very 
entrance  of  our  bodies,  and  so  placed  that  they  must  pass  in  immense 
numbers  into  the  stomach  whenever  we  swallow  anything,  is  a  fact  of 
great  significance  in  connection  with  certain  conclusions  respecting  the 
action  of  these  low  organisms  upon  the  solids  and  fluids  of  man's  body. 
Of  late  years,  the  idea  that  such  organisms  constitute  the  active  par- 
ticles concerned  in  the  propagation  of  contagious  disease, — are,  in  fact, 
the  actual  materies  morbi, — has  been  increasingly  popular.  The  first 
question  you  will  ask  will  probably  be  this  : — Do  these  germ-particles 
perform  any  distinct  office  or  function  in  connection  with  the  solution 
of  food  or  digestion,  or  do  they  merely  live  and  grow  upon  the  old 
epithelial  cells  and  the  debris  of  the  food  which  must  needs  undergo 
change  in  such  a  situation,  and  at  the  temperature  of  the  inside  of  the 
mouth?  We  find  such  bodies  in  animals  as  well  as  man,  and  though 
they  are  found  in  greatest  number  in  certain  derangements,  multitudes 
are  constantly  present  in  the  most  healthy  individuals.  They  have  no 
doubt  grown  and  multiplied  under  similar  conditions  and  without  vary- 
ing in  character  for  thousands  of  years. 

Wherever  organic  matter  is  undergoing  change  and  disintegration  in 
an  organism,  or  outside  it,  at  the  temperature  of  man's  body,  or  some 
degrees  lower  or  higher  than  this,  and  in  some  cases  at  a  much  lower 
temperature,  such  organisms  exist  in  countless  multitudes,  and  grow 
and  multiply  at  the  expense  of  the  disintegrating  organic  matter. 
In  the  autumn  there  is  not  a  leaf  in  which  you  will  not  find  millions 
of  low  vegetable  organisms  in  various  stages  of  development  and 


BACTERIA   IN  LIVING  PLANTS.  47 

growth.  As  the  organic  matter  of  the  dying  leaf  or  plant  undergoes 
change,  and  the  decomposition  of  its  more  unstable  compounds  com- 
mences, the  circumstances  specially  favorable  for  the  growth  and  mul- 
tiplication of  many  of  the  microscopic  fungi  are  established.  Fungus 
germs  exist  in  the  air  at  every  part  of  the  earth's  surface  at  all  times. 
Though  by  no  means  constantly  present  in  precisely  the  same  amount, 
some  are  always  to  be  detected  in  appreciable  numbers,  if  the  air  is 
properly  examined.  Many  coming  into  contact  with  the  moist  sur- 
face of  the  leaf  about  to  decay,  find  there  a  surface  favorable  for 
their  development.  The  spores  germinate,  and  from  the  surface  of 
the  tissues  of  the  plant  the  growth  easily  makes  its  way  into  the 
substance. 

But  is  it  not  remarkable  that  any  one  should  believe,  on  the  one  hand, 
that  the  decay  of  the  leaves  is  due  to  the  fungi,  or,  on  the  other,  that 
the  decay  is  the  cause  of  their  development,  growth,  and  multiplication? 
All  that  can  be  proved  by  facts  and  observation  is,  that  as  the  leaf 
grows  old,  substances  are  formed  which  are  easily  appropriated  by  the 
fungi.  The  germs  of  fungi  are  present  and  are  ready  to  develop  just  at 
the  time  when  the  appropriate  pabulum  is  formed.  The  fungus  does 
not  spring  from  the  leaf,  neither  is  the  leaf  caused  to  grow  old  by  the 
fungus,  and  its  deterioration  begins  before  the  growth  of  the  fungus 
commences.  The  fungus  is  in  no  sense  either  the  cause  or  the  conse- 
quence of  the  decay.  And  in  the  case  of  the  higher  animals  and 
man,  at  leastxin  many  instances  in  which  low  organisms  are  associated 
with  morbid  processes,  these  last  are  neither  the  cause  of  disease  nor 
are  they  produced  by  it.  Fungus  germs  and  micrococci  of  various 
kinds,  being  present,  will  grow  and  multiply  whenever  the  surrounding 
conditions  become  favorable  for  the  multiplication  of  each  particular 
kind.  If  these  conditions  remain  for  a  considerable  time  unfavorable, 
the  germs,  if  present,  remain  quiescent,  and  may  at  last  die,  though 
probably  most  of  such  germs  retain  their  vitality  in  a  quiescent  state 
for  many  years,  and  some  perhaps  for  centuries. 

Nor  are  microscopic  fungi  found  only  at  this  period  of  the  year 
(autumn)  in  connection  with  dead  and  decaying  vegetable  tissue.  In 
the  vegetables  and  fruit  we  eat  are  countless  multitudes  of  living  grow- 
ing organisms.  Look,  for  instance,  at  the  cells  of  a  piece  of  lettuce  or 
of  the  leaf  of  the  watercress,  nay,  even  those  in  the  leaf  and  stem  of  the 
young  and  rapidly  growing  mustard  and  cress.  There  you  will  find,  if 
you  examine  thin  sections  or  the  separated  cells  under  a  magnifying 
power  of  three  hundred  diameters  or  more,  millions  of  little  bodies, 
each  of  which  is  capable  of  giving  rise  to  countless  multitudes  in  a  very 
short  time.  If  you  carefully  study  the  revolving  living  matter  of  the 
cell  of  the  leaf  of  the  Vallisneria,  you  will  have  no  difficulty  in  discern- 
ing some  of  these  very  low  organisms  in  close  proximity  to  the  living 


48  BACTERIA   IN  LIVING  ANIMALS. 

matter  of  the  plant  itself.  So  very  near,  indeed,  is  the  lowest  living 
particle  to  the  highest  during  its  life,  that  no  wonder  the  material  of  the 
latter  falls  a  prey  to  it  at  last.  The  instant  matter  ceases  to  live  it  is 
invaded  and  appropriated  by  the -ever-growing  bacterium — the  most 
constant,  the  most  unchanging  and  universal  of  all  kinds  of  living 
things — and  of  all  the  survivor;  but  whether  this  be  of  all  things  the 
most  fit  to  survive,  you  may  decide  if  you  can. 

As  it  is  with  regard  to  deteriorating  vegetable  tissues,  so  it  is  with 
regard  to  decaying  animal  tissue.  Whether  the  body  be  in  a  state 
of  health  or  disease,  wherever  tissue  is  about  to  undecgo  active  disin- 
tegrating chemical  change,  wherever  decomposition  is  taking  place,  or 
is  approaching,  the  conditions  may  be  favorable  for  the  growth  and 
multiplication  of  certain  low  organisms,  the  germs  of  which  are  present. 
Long  before  any  changes  akin  to  deterioration  and  decay  are  ordinarily 
supposed  to  commence,  even  from  the  very  earliest  period  of  construc- 
tion and  growth,  fungus  germs  are  ever  present,  ready  to  grow  and 
multiply  should  the  death  and  disintegration  of  a  living  particle  occur. 
No  wonder,  then,  that  we  find  so  many  low  organisms  growing  in 
connection  with  the  old  decaying  epithelium  of  the  mouth  and  of  the 
tongue,  of  the  oesophagus,  and  other  parts.  Under  certain  circum- 
stances, the  fungi  grow  and  multiply  to  a  vast  extent  lower  down  the 
alimentary  canal,  as  I  shall  presently  explain.  We  cannot  suppose  that 
such  organisms  do  any  harm ;  for  patients  suffering  from  maladies  in 
which  the  alimentary  canal  seems  to  be  almost  filled  with  bacteria 
recover,  without  damage  to  any  textures  having  been  occasioned. 

I  have  not  studied  the  epithelium  from  the  mouth  of  a  savage  who 
has  never  been  in  contact  with  civilized  man,  but,  without  having 
actually  looked,  I  think  I  may  feel  pretty  confident  that  low  vegetable 
organisms  would  be  found  growing  in  the  cells  just  as  they  grow  in 
those  of  our  own  mucous  membrane,  and  the  species  are  probably  pre- 
cisely the  same. 

In  lower  animals,  organisms  of  the  same  general  character  abound. 
If  you  examine  the  tongue  of  the  dog  or  of  the  cat,  of  the  sheep  or  of 
the  ox,  you  will  find  that  the  same  sort  of  changes  are  constantly  going 
on.  Everywhere  the  old  epithelial  cells  are  being  invaded  by  low 
vegetable  organisms,  which  grow  and  multiply  as  they  do  in  the  epi- 
thelial cells  of  man  himself.  Multitudes,  of  course,  pass  down  into  the 
stomach,  and,  under  ordinary  circumstances,  many  are  probably  de- 
stroyed during  digestion  by  the  action  of  the  gastric  juice  and  bile,  and 
other  fluids,  which  are  poured  into  the  alimentary  canal.  Those  that 
are  not  destroyed  certainly  do  no  harm.  In  the  healthy  state  they 
either  do  not  grow  and  multiply  at  all  during  digestion  and  assimila- 
tion, or  only  to  a  very  slight  extent. 

In  the  case  of  the  lower  animals,  the  introduction  of  fungi  into  the 


BACTERIA   IN   THE   INTESTINES.  49 

stomach  goes  on  constantly  and  upon  an  enormous  scale.  Every 
mouthful  of  water  consumed  by  sheep,  oxen,  and  other  animals,  teems 
with  myriads  of  low  vegetable  and  animal  organisms  in  various  stages  of 
existence  ;  and  in  the  food  they  take,  fungi  in  various  stages  are  present, 
as  well  as  the  sporules  of  many  different  species.  These  low  organisms 
are,  therefore,  always  passing  into  the  bodies  of  the  animals  in  count- 
less multitudes.  But  although  millions  of  living  fungi  are  always  enter- 
ing the  alimentary  canal  of  man  and  animals  without  doing  harm,  and 
probably  without  growing  and  multiplying  there  to  any  great  extent, 
there  are  circumstances  under  which  a  different  state  of  things  is 
observed.  If  the  stomach  is  out  of  order,  if  the  bile  and  other  secre- 
tions are  deranged,  or  from  some  temporary  or  permanent  impediment 
to  their  escape  are  not  poured  into  the  alimentary  canal  in  propei 
quantity,  phenomena  totally  unlike  those  characteristic  of  the  healthy 
state  are  induced.  Many  an  infant  has  suffered  from  the  extraordinary 
development  of  bacteria  in  its  alimentary  canal,  and  some  children  die 
from  the  state  of  things  thereby  induced.  But  the  bacteria  cannot  cor- 
rectly be  regarded  as  the  cause  of  the  departure  from  the  normal, state. 
That  is  to  be  sought  in  the  secretions  and  in  the  action  of  the  glands 
prior  to  the  multiplication  of  the  organisms. 

I  have  seen  every  part  of  the  cavity  of  the  stomach,  and  the  small  and 
large  intestine  of  an  infant  filled  with  curdled  milk  which  had  not  under- 
gone the  slightest  digestion,  and  every  particle  of  which,  when  under 
the  microscope,  seemed  to  be  almost  composed  of  bacteria,  so  abundant 
were  these  bodies.  Sometimes,  however,  bacteria  grow  and  multiply  in 
the  milk  of  the  mother  before  it  has  escaped  from  the  breast,  and  the 
changes  effected  in  the  milk  by  the  growth  and  multiplication  of  the 
organisms,  it  need  scarcely  be  said,  render  it  quite  unfit  for  the  suste- 
nance of  the  infant ;  and  such  milk,  were  it  taken,  would,  except  perhaps 
in  the  very  strongest  children,  give  rise  to  serious  derangement  of  the 
digestive  organs.  In  such  a  case  the  maternal  secretion  must  have  been 
out  of  order  at  the  time  of  its  secretion,  or  the  bacteria  would  not 
have  grown  and  multiplied  in  it.  It  is  certain  that  in  such  secretions 
and  in  the  glands  that  produce  them,  bacteria-germs  are  always  present, 
but  do  not  increase  and  multiply  until  long  after  the  secretion  has  been 
discharged  from  the  gland. 

In  face  of  such  facts,  it  is  difficult  to  accept  the  doctrine  that 
bacteria,  fungi,  and  such  like  low  organisms  are  morbific,  or  disease- 
producing  agents,  or  are  of  themselves  productive  of  harm  to  the 
organism  into  which  they  pass.  It  is  astonishing  that,  notwithstanding, 
these  facts,  which  can  be  verified  by  any  one — facts  with  which  many 
of  us  have  been  familiar  for  the  last  thirty  years  and  more — should 
at  this  time  be  unknown  to,  or  somehow  escape  the  cognizance  of,  some 
who  have  been  recently  studying  the  life-history  of  these  very  organisms. 
5  D 


5<D  DUST  NOT  DISEASE. 

The  knowledge  of  such  broad  general  facts  renders  it  difficult,  I  think, 
to  accept  off-hand  the  doctrine  that  such  organisms  are  somehow 
intimately  connected  with  the  origin  and  communication  of  many  of 
the  most  serious  diseases  of  man  and  animals.  Of  late  years,  however, 
the  theory  that  such  organisms,  which  are  invariably  present  in  all 
decaying  healthy  normal  structure,  or  closely  allied  organisms,  or  their 
pathologically  modified  descendants,  constitute  the  actual  poison  of 
most  of  the  contagious  diseases  which  invade  us,  has  spread  far  and 
wide,  and  has  been  accepted  by  many  as  a  general  principle. 

There  is,  probably,  not  a  part  of  the  body  of  any  one  of  us  of  a 
quarter  of  an  inch  in  diameter  where  bacteria-germs  are  not  present. 
Certainly  every  time  we  eat,  myriads  are  carried  into  our  alimentary 
canal ;  and  every  time  we  breathe,  except  in  the  very  purest  atmosphere, 
multitudes  pass  into  the  air-passages.  So  small  are  these  bacterial 
germs,  that  they  would  pass  without  the  slightest  difficulty  through 
basement  membrane  and  through  the  interstices  of  any  of  the  tissues  of 
the  organism ;  and  yet  the  public  is  taught  that  there  is  some  intimate 
connection  between  bacteria,  and  dust,  and  morbid  phenomena. 
Erroneous  notions  are  spread  far  and  wide  by  sensation  lectures,  under 
such  a  title  as  "  Dust  and  Disease."  The  dust  which  causes  disease  is 
of  a  most  exceptional  kind.  It  has  been  said  that  the  air  of  the  Swiss 
mountains  is  devoid  of  bacteria.  But  is  the  health  and  vigor  of  the 
inhabitants  of  the  Alps  to  be  compared  with  that  of  the  workers  on  the 
Paddington  Dust  Heaps?  As  a  fact,  ordinary  bacteria  are  harmless 
enough  ;  they  exist  in  us  without  disturbing  us  in  any  way,  but  they 
only  grow  and  multiply  in  great  numbers  when  circumstances  become 
favorable.  I  can  give  you  positive  proof  that  bacteria  germs  exist  not 
only  upon  the  surface  of  the  skin  and  mucous  membranes,  but  in  the  in- 
ternal organs,  in  the  interstices  of  healthy  tissues,  and  in  the  blood  itself. 
Some  years  ago  I  examined  the  layers  of  a  fibrinous  clot  which  had  been 
slowly  formed  from  the  blood  in  the  interoir  of  a  large  aneurism  of  the 
aorta  of  a  man  who  died  of  the  disease.  The  body  was  examined  six  or 
eight  hours  after  death.  The  aneurism  had  existed  for  many  years ;  and 
probably  some  of  the  layers  of  fibrin  which  had  been  deposited  were 
almost  as  old  as  the  aneurism  itself.  Now  I  found  that  in  all  parts  of 
the  firm,  laminated,  leather-like  material,  which  served  to  greatly  increase 
the  thickness  of  the  wall  of  the  aneurismal  sac,  there  were  indications  of 
disintegrating  changes  having  taken  place.  Upon  carefully  examining 
minute  pieces  of  the  fibrin  under  high  powers,  multitudes  of  bacteria 
and  their  germs  were  discovered  without  difficulty.  But  the  older 
layers  in  the  outer  part  were  here  and  there  softened,  and  portions  of 
the  fibrinous  matter  seemed  eroded,  many  small  masses  of  soft  and 
broken-down  material  being  present.  All  these  teemed  with  bacteria, 
moving,  growing,  and  multiplying. 


BACTERIA   IN  THE    VESSELS.  51 

Now  these  bacteria,  like  the  fibrin  in  which  they  were  growing  and 
multiplying,  were  very  close  to  the  blood  and  within  the  vascular 
system  ;  internal  to  the  various  tissues  constituting  the  wall  of  the  vessel, 
which  was  dilated  to  form  the  aneurismal  sac.  The  bacteria  must  have 
been  growing  and  multiplying  in  the  lifetime  of  the  patient,  and  pro- 
bably for  many  months  before  his  death  occurred.  They  could  not 
have  got  into  the  position  in  which  they  were  discovered  from  the  out- 
side, for  it  is  hardly  conceivable  that  such  an  organism  as  a  bacterium 
could  have  found  out,  while  outside  the  body,  that  within  the  vas- 
cular system  there  was  material  suitable  for  its  growth  and  multipli- 
cation. Neither  is  it  possible  the  bacteria  could  have  made  their  way 
from  without  to  the  situation  in  which  they  were  found,  nor  could  they 
have  effected,  in  the  course  of  a  few  hours,  the  extensive  erosions  and 
softening  discovered.  Such  theories  could  not  be  sustained  with  any 
show  of  reason.  The  only  conclusion,  therefore,  which  is  in  accordance 
with  the  facts  of  the  case  and  with  common  sense,  is  that  which  I  have 
before  adverted  to:  viz.,  that  bacteria-germs  exist  at  all  times  in  all 
parts  of  the  body,  even  in  the  blood  itself  during  the  healthy  state. 

I  conclude  that  as  long  as  the  normal  state  of  things  exists,  the 
living  bacteria-germs  in  all  parts  of  the  organism  do  not  grow  and 
multiply,  but  that  when  any  change  occurs  of  the  character  of  that  which 
results  in  chemical  decomposition,  these  bacteria-germs  multiply.  This 
multiplication  proceeds,  although  we  are  alive,  just  as  it  takes  place  in 
dead  animal  and  vegetable  matter.  And  it  will  occur  in  every  part  of 
every  one  of  us  a  very  few  hours  after  death. 

So  that  you  see  if  bacteria-germs  constitute  the  actual,  material, 
living  particles  by  which  contagious  disease  is  propagated,  they  must 
be  peculiar  bacteria,  totally  different  from  the  ordinary  bacteria-germs 
which  exist,  and  have  existed  everywhere.  The  ordinary  bacteria  may 
certainly  grow  and  multiply  enormously  on  the  mucous  membranes  of 
the  body,  in  follicles  of  the  mucous  surfaces,  and  in  viscera, — intestinal 
canal,  bladder,  and  passages  therefrom,  nay,  even  amongst  the  elements 
of  healthy  growing  tissue,  without  causing  any  disease  at  all.  Bacteria- 
germs,  low  fungi,  and  low  algae  exist  in  connection  with  the  tissues  and 
fluids  of  every  human  organism,  and,  as  you  may  convince  yourselves 
at  any  time,  millions  of  these  are  unquestionably  present  during  every 
moment  of  existence  in  health  on  the  surface  of  the  dorsum  of  the 
tongue.  Multitudes,  as  I  have  said,  pass  down  the  alimentary  canal 
every  time  we  swallow  food  or  fluid.  Such  ordinary  bacteria  and  their 
germs  do  us  no  harm  whatever.  But  please  do  not  infer  from  what  I 
have  said  that  putrid  fluids  loaded  with  bacteria  are  innocuous  or  to  be 
recommended.  Organic  matter  in  a  state  of  putrefactive  decomposition 
when  introduced  into  the  alimentary  canal  gives  rise  to  pathological 
phenomena  irrespective  of  the  bacteria  it  may  contain. 


52  BACTERIA   PATHOLOGICA. 

Some  have  attempted  to  surmount  the  difficulty  of  accounting  for  the 
origin  of  such  a  multitude  of  bacterial  species  or  varieties,  each  having 
the  power  or  property  of  causing  a  definite  disease,  by  the  conjecture 
that  ordinary  bacteria,  like  higher  organisms,  are  themselves  the  subjects 
of  pathological  evolutional  changes.  It  is  surmised  that  the  ordinary 
bacterium  living  under  altered  conditions,  might  give  origin  to  a  patho- 
logical bacterium,  and  these  might  further  change,  and  thus  give  rise  to 
new  disease-producing  organisms.  In  this  way,  conjecture  is  added  to 
conjecture,  and  the  evolution  of  one  hypothesis  leads  to  the  evolution  of 
another.  New  forms  of  being  are  assumed,  and  pathological  prodigies 
are  added  to  the  multitudinous  new  creations  of  the  evolutional  imagi- 
nation. As  a  fact,  we  find  that  pathological  phenomena  become  less 
distinct  as  we  descend  in  the  scale  of  created  beings,  and  it  is  doubtful 
if  in  the  lower  simpler  forms  of  life  any  phenomena  occur  to  which  the 
term  pathological  or  morbid  is  strictly  applicable.  That  an  Actinia  or 
a  Hydra  may  suffer  from  pathological  change  is  certain,  but  organisms 
much  lower  and  simpler  than  these,  are  probably  incapable  of  undergoing 
change  which  could  be  properly  regarded  as  morbid  or  pathological. 

The  suggestion  of  bacteria  taking  upon  themselves  a  sort  of  patho- 
logical transformation,  and  developing  by  degradational  evolution  a  bac- 
terium of  vileness  and  virulence  potent  to  produce,  it  maybe,  new  and 
fatal  forms  of  disease,  strikes  me  as  a  wonderful  conjecture,  even  in  these 
days  of  rampant  scientific  fancy,  and  as  gratuitous  as  it  is  unnecessary. 
The  broad  facts  of  nature  are  entirely  opposed  to  it.  So  far  from  any 
observations  yet  made  being  in  its  support,  there  is  potent  evidence 
against  such  an  hypothesis.  Conditions  which  in  high  and  complex 
organisms  would  result  in  pathological  phenomena,  in  these  low  forms 
merely  determine  an  alteration  in  the  rate  of  growth  and  multiplication. 
The  change  in  such  an  organism  as  the  yeast  plant,  which  seems  to 
correspond  to  the  formation  of  pus  in  man  and  the  higher  animals,  is 
but  more  rapid  multiplication,  by  the  division  and  subdivision  of  the 
living  matter  (bioplasm),  of  the  minute  and  simple  organism.  The 
bacterium  would  appear  to  be  much  lower  and  simpler  as  regards  the 
varied  conditions  under  which  it  lives  and  grows  than  the  yeast  plant. 
Indeed,  the  bacterium  is  one  of  the  most  constant  and  unchangeable  of 
all  forms  of  life,  and  if  altered  forms  spring  from  it,  they  soon  revert  to 
the  primitive  universal  constant  form. 

Still,  it  might  be  said,  that  it  is  possible  that  great  change  in  sur- 
rounding conditions  might  cause  the  development  of  bacteria  with  new 
disease-causing  powers,  from  pre-existing  harmless  or  disease-producing 
varieties  or  species.  There  are,  however,  serious  objections  to  adopting 
such  an  hypothesis,  among  which,  by  no  means  the  least,  is  the  neces- 
sity of  accepting  several  minor  hypotheses  involved  in  the  acceptance  of 
the  major.  It  is  most  difficult  to  see  how  and  why  the  supposed  new 


BACTERIA   MOST  ANCIENT.  53 

forms  should  begin.  Indeed,  looking  broadly,  one  most  striking  fact 
in  connection  with  bacteria  is,  that  countless  millions  of  similar  forms 
resulting  from  endless  repetition  have  been  produced  without  change 
in  power  through  past  ages.  We  must  be  very  careful  as  regards  the 
acceptance  of  so-called  evidence  of  change  in  property  and  power  of 
organisms  of  this  low  class.  It  is,  I  readily  admit,  not  unreasonable  to 
suppose  that  changes  within  certain  definite  limits  may  occur,  but  in 
some  cases  what  seem  to  be  new  forms,  are  probably  but  temporary 
modifications,  the  descendants  of  which  soon  resume  the  old  type: 
Divergence  and  reversion  in  a  limited  and  very  moderate  degree,  and 
possibly  in  forms  of  life  much  higher  than  the  bacterium,  may  occur, 
and  be  frequently  repeated,  without  ever  leading  to  or  resulting  in  any 
lasting  change  of  type. 

Time  will  probably  show  that  many  of  the  pretentious  statements 
which  have  been  made  concerning  the  fungus  germ  hypothesis  of  conta- 
gious disease,  are  groundless. 

It  has  been  clearly  shown,  that  as  the  bioplasm  of  man's  body 
acquires  increased  power  of  growth,  it  also  acquires  increased  power  of 
resisting  the  destructive  influence  of  external  conditions.  The  move- 
ments of  the  morbid  bioplasm  of  the  pus-corpuscle  will  continue 
long  after  those  of  the  healthy  bioplasm  of  the  white  blood-corpuscle 
have  ceased.  It  is  certain,  that  other  forms  of  morbid  bioplasm 
originating  in  man's  body  exhibit  far  greater  resisting  power  than 
that  manifested  by  pus.  These  and  many  more  cogent  and  striking 
facts  are  wholly  ignored  by  writers  of  the  bacterial  school,  and  by 
those  whose  general  views  are  founded  on  highly  partial  considera- 
tions, and  whose  judgment  seems  to  have  been  warped  from  the 
first  by  the  assertions  and  extraordinary  delineations  of  speculative 
observers  like  Hallier.  In  spite  of  all  that  has  been  urged  in  favor-of  a 
bacterium  hypothesis,  it  must  at  this  time  be  admitted  that  in  no  case 
has  the  specific  bacterium,  of  any  definite  disease  been  identified.  The 
ordinary  bacterium  is  certainly  the  least  varying  of  all  living  forms.  The 
organism  that  grew  and  multiplied  in  the  dead  bodies  of  the  Pharaohs 
is  probably  identical  with  that  which  is  associated  with  the  decom- 
position of  the  organic  matter  of  the  human  body  in  our  own  time.  Nor 
is  there  any  reason  to  suppose  that,  should  the  world  last  as  long,  any 
alteration  will  take  place  in  the  characters,  mode  of  growth,  and  disin- 
tegrating activity  of  the  bacterium  some  thousands  of  years  hence. 

It  seems  to  have  been  forgotten  that  the  chemical  substances  in 
many  putrefying  organic  matters  act  as  poisons  to  the  living  matter  of 
the  tissues  and  organs  of  the  body.  These  substances  passing  to  the 
bioplasm  quickly  destroy  it,  and  the  material  around  each  living  mass,  no 
longer  being  traversed  by  fresh  particles  of  fluid  as  in  health,  passes  into 
decomposition  :  and  so  the  process  goes  on,  until  a  considerable  pro- 


54  NATURE    OF  CONTAGIUM. 

portion  of  tissue  is  destroyed,  and  passes  into  a  state  of  putrefaction. 
In  many  such  cases  the  blood  itself  is  poisoned,  and  it  may  be  at  an 
early  period  of  the  change.  But  for  all  this,  an  exceptional  state  of  things 
is  in  the  first  instance  necessary.  The  phenomena,  which  in  the  higher 
organisms  ordinarily  interfere  with  the  growth  and  multiplication  of  the 
ever-present  bacteria,  must  have  given  place  to  very  exceptional  changes, 
and  these,  not  the  bacteria,  must  be  regarded  as  the  true  cause  of  the 
disease. 

'  It  has  been  objected  that  the  materies  morbi  of  contagious  diseases 
cannot  consist  of  the  modified  living  matter  of  the  body  itself,  because 
the  healthy  living  matter  rapidly  undergoes  change  when  removed  from 
the  seat  of  its  growth,  and  very  soon  dies.  But  he  who  accepts  this 
apparent  objection  must  at  the  same  time  ignore  most  important  facts, 
and  must  forget  that,  for  example,  healthy  ciliated  cells  retain  their 
vitality  for  many  days  after  the  death  of  the  body ;  the  bioplasm  at  the 
base  of  the  hair,  and  that  in  the  deep  layers  of  the  cuticle,  also  resists 
the  destructive  influences  which  quickly  kill  the  living  matter  of  many 
other  parts  of  the  healthy  body.  But,  worse  than  all,  the  important 
fact  I  have  urged  in  favor  of  my  view  remains  unanswered,  and  is, 
indeed,  wholly  ignored  by  those  who  accept  hypotheses  concerning  very 
difficult  questions,  which  have  the  great  advantage  of  being  well  talked 
of,  but  little  thought  about. 

In  concluding  my  remarks  on  this  very  important  and  highly  in- 
teresting question,  I  venture  to  ask  you  to  bear  in  mind  that  the 
bacterium  and  its  germs  are  intimately  associated  with  every  kind  of 
animal  and  plant,  in  its  healthy  and  morbid  state  and  during  every 
period  of  existence,  from  its  earliest  embryonic  condition  to  the  time  of 
death  at  the  most  advanced  age.  Whether  it  is  some  special  bacterium 
which  directly  causes  the  results  consequent  upon  the  introduction  of  a 
specific  poison  into  the  organism,  or  whether  the  active  particle,  the 
contagium  or  materies  morbi,  is  of  a  totally  different  nature,  altogether 
independent  of  bacteria  and  allied  organisms,  must  be  regarded  as  still 
an  open  question.  Some  statements,  it  must  be  admitted,  have  been 
recently  made  in  favor  of  the  hypothesis  that  there  are  bacteria  and 
bacteria — that  the  real  contagious  bacterium  is  an  organism  altogether 
apart  from  the  harmless  bodies  so  intimately  associated  with  the  tissues 
and  fluids  of  every  one  of  us ;  but,  as  I  have  endeavored  to  show,  the 
arguments  hitherto  advanced  are  by  no  means  convincing.  Further, 
as  I  have  endeavored  to  explain,  it  has  been  conjectured  that  the 
horrible  death-carrying  bacteria  of  various  orders  have  been  somehow 
derived  from  the  harmless  form  by  pathological  transformations,  or 
developed  in  the  course  of  evolutional  struggles  proceeding  through  the 
ages,  or  that  they  are  the  product  of  a  constantly  altering  environment. 
Buf,  it  need  scarcely  be  said,  many  new  facts  must  be  discovered,  and 


TONGUE  IN  DERANGEMENTS.  55 

much  must  be  learned  concerning  special  bacterial  phenomena  before  the 
problem  can  be  solved.  I  have  alluded  to  these  views  here  in  order 
that  the  most  important  points  may  be  before  you,  and  I  hope,  in  con- 
sidering them,  you  will  keep  prominently  before  your  mind's  eye  this 
one  universal,  ever-existing,  unchangeable  organism,  which,  possibly  the 
first  formed  of  all  life,  has  outstood  every  change,  and  is  probably 
destined  to  outlast  every  other  living  form,  which  is  domiciled  in  every 
organism  on  the  face  of  the  earth,  is  found  in  almost  every  kind  of  food 
and  drink,  flourishes  in  the  human  mouth,  and  the  germs  of  which  are 
to  be  found  in  every  part  of  man's  body,  and  which  is  conjectured  to 
be  closely  related  to  the  living  forms  which  cause  various  contagious 
diseases,  and  to  have  given  origin  to  them. 

The  Tongue  in  various  Derangements. 

I  shall  now  proceed  to  consider  a  little  more  in  detail  the  changes 
which  occur  in  the  tongue,  which  are  of  special  interest  to  us,  and  the 
peculiar  characters  assumed  by  the  organ  in  different  states  of  health. 
The  subject  has  received  great  attention  from  the  very  earliest  ages,  and 
not  only  from  medical  practitioners.  It  is  in  all  respects  worthy  of 
your  most  attentive  consideration.  Not  a  few  persons,  ignorant  of 
medicine,  have  been  in  the  constant  habit  of  studying  the  state  of  the 
tongue.  To  many  it  is  a  matter  of  grave  anxiety  through  life,  and  men 
have  been  known  to  use  the  looking-glass  every  day  for  half  a  century 
or  more  for  the  purpose  of  observing  the  daily  changes  which  occur. 
Especially  does  the  tongue  excite  the  greatest  attention  and  interest 
among  the  members  of  that  large  section  of  civilized  man  which  knows 
not  what  it  is  to  feel  perfectly  well — to  be  free  from  discomfort  of  every 
kind,  and  not  to  ail  anything. 

It  has  been  already  stated  that  changes  in  the  tongue  are  frequently 
associated  with  somewhat  similar  changes  occurring  in  other  parts  of 
the  very  extensive  system  of  mucous  membrane  concerned  in  the  prep- 
aration, digestion,  and  absorption  of  food.  We  have  now  to  consider 
how  such  extensive  changes  are  probably  occasioned.  One  part  of  the 
mucous  tract  may  participate  in  the  phenomena  occurring,  it  may 
be,  at  a  considerable  distance.  This  participation  is  doubtless  due  to 
the  circumstance  that  the  nerve-centres  presiding  over  the  several 
actions  occurring  in  different  parts  of  the  mucous  membrane  of  the 
alimentary  canal  are  connected  together  by  commissural  fibres.  The 
actions  of  the  numerous  minute  nerve-centres  are  also  harmonized  and 
co-ordinated  by  intercommunicating  cords. 

The  extensive  gastro-intestinal  tract  of  mucous  membrane  is  indeed 
supplied  with  one  system  of  nerves,  the  great  characteristic  of  which  is 
extensive  distribution  and  intimate  intercommunication,  so  that  when 
one  portion  is  deranged  the  action  of  others  is  often  disturbed.  In 


$6  CHANGES  IN  THE    TONGUE. 

certain  forms  of  disease  a  local  affection  of  very  limited  extent  often 
provokes  an  altered  and  pathological  action  of  twenty  or  thirty  feet  of 
intestine  or  more,  and  may  affect  the  character  of  the  secretions  from 
gastric  and  intestinal  glands  at  a  great  distance  from  the  seat  of  actual 
lesion. 

Very  slight  changes  as  regards  diet  will  lead  to  reduction  of  the 
secreting  action  of  the  stomach  glands.  The  mucous  membrane  often 
becomes  less  moist  than  it  should  be,  and  the  secretion  from  every  part 
is  reduced,  though  it  would  be  incorrect  to  say  that  the  membrane 
became  dry.  The  mucous  membrane  of  the  mouth  and  the  glands 
connected  therewith  may  participate  in  any  altered  action  going  on  in 
the  stomach.  In  practice  we  invariably  find  that  in  fevers,  and  indeed 
in  any  slight  attack  of  feverishness,  when  the  temperature  of  the  body 
has  risen  only  two  or  three  degrees,  in  short,  in  the  common  patholog- 
ical change  which  everybody  has  experienced  when  he  has  taken  cold, 
there  is  imperfect  action  and  deranged  secretion  in  the  stomach.  For 
several  hours,  it  may  be  for  two  or  three  days,  there  is  in  most  cases 
defective  formation  of  the  substances  which  form  the  all-essential  con- 
stituents of  saliva,  the  gastric  juice,  and  other  secretions  poured  into 
the  intestinal  canal.  One  consequence  is  that  the  ordinary  desire  for 
eating  is  not  present,  and  if  the  person  eat  well  in  spite  of  his  dis- 
inclination to  do  so,  further  derangement,  perhaps  severe  pain  and  in- 
digestion, may  add  to  his  .troubles,  if  he  has  not  the  good  fortune  to 
escape  by  free  vomiting  or  by  the  occurrence  of  diarrhoea,  or  both. 
Under  such  circumstances  it  is,  therefore,  the  best  plan  to  starve,  or, 
if  the  person  is  weak  and  feeble,  he  might  take  milk,  beef-tea,  or  strong 
soup  in  very  small  quantities,  at  short  intervals  of  time  (an  hour  or  two 
hours)  until  healthy  action  returns. 

It  is  probable  that  under  the  circumstances  I  am  considering,  the 
various  materials  out  of  which  the  mucus  which  is  secreted  on  the 
surface  of  the  mucous  membranes  and  by  the  glands  connected  with 
'them,  are  not  separated  from  the  blood,  or  are  present  in  an  altered 
state.  In  fevers,  and  even  in  slightly  feverish  conditions,  I  believe  that 
those  complex  compounds  from  which  the  cells  of  the  salivary  glands 
form  saliva,  and  those  out  of  which  the  gland  cells  of  other  parts  of 
the  alimentary  canal  develop  the  marvellous  and  peculiar  substances 
which  play  so  important  a  part  in  digestion  and  ultimately  in  nutrition, 
are  not  drawn  from  the  blood  through  the  walls  of  the  vessels.  This 
deranged  action  of  an  extensive  system  of  glandular  organs  necessarily 
affects  the  composition  of  the  blood  (which  also  suffers  in  other  ways), 
and  thus  the  action  of  every  tissue  and  organ  in  the  body  may  for  a 
time  become  more  or  less  deranged. 

When  we  come  to  consider  the  nature  of  the  changes  occurring  in 
feverishness,  we  shall  see  that  in  all  fevers,  and  in  every  febrile  condi- 


IMPORTANCE   OF  SECRETION.  5/ 

tion,  digestion,  and  the  action  of  the  alimentary  canal  are  invariably 
disturbed,  and  often  to  an  alarming  extent.  Every  intelligent  mother 
knows  that  in  infants  and  in  young  children  the  febrile  state  often  com- 
mences with  derangement  of  the  stomach,  and  may  be  occasioned  by 
improper  food,  as,  for  example,  hard,  unripe  apples.  In  this  way  im- 
portant alterations  in  the  blood  and  general  derangement  of  the  system 
result  from  pathological  phenomena,  which  start  from  disturbance  in 
the  action  of,  it  may  be,  only  a  small  portion  of  the  mucous  membrane 
of  the  alimentary  canal. 

It  is  very  important  that  the  organs  whose  action  is  disturbed  should 
be  permitted  to  rest  for  awhile.  You  will  find  after  a  time  there  will  be 
good  evidence  of  returning  action,  and  possibly  of  undue  action.  A 
greater  amount  of  action  than  occurs  in  health  may  be  noticed,  but 
this  is  soon  followed  by  reduced  activity,  and  at  length  the  proper 
degree  of  action.  By  degrees  the  normal  state  of  health  is  re-estab- 
lished, without  any  permanent  lesion  or  structural  change  of  any  kind 
having  been  induced.  In  such  derangements,  if  by  any  means  we  can 
cause  the  return  of  secreting  action,  if  we  can  get  these  various  glands 
to  act  freely,  the  abnormal  condition  will  be  relieved,  and  the  normal 
or  healthy  state  restored,  sooner  than  if  matters  are  left  to  right  them- 
selves. In  this  way  the  patient  would  gain  an  important  advantage.  I 
think  I  shall  be  able  to  convince  you  that  we  can  be  of  use,  not  only  by 
effecting  the  expulsion  of  the  irritating  matters  from  the  stomach  or 
bowels,  but  also  by  diminishing  the  febrile  condition  set  up  in  these 
cases,  and  in  others  in  which  febrile  development  is  more  obscure  and 
difficult  to  trace.  It  will  be  well  for  me,  before  further  discussing  this 
part  of  the  matter,  to  draw  your  attention  to  one  or  two  other  points  of 
general  interest  in  connection  with  the  febrile  state. 

In  an  ordinary  cold  the  mouth  is  often  more  or  less  dry  or  clammy. 
The  throat,  as  you  know,  feels  dry  and  rough,  and  the  appetite  becomes 
impaired.  Little  gastric  juice  is  formed  under  these  circumstances,  and 
probably  the  quantity  of  intestinal  fluid  that  ought  to  be  secreted  is 
much  less  than  usual.  You  will  also  notice,  if  you  pay  careful  attention 
to  the  matter,  that  the  kidneys  do  not  secrete  in  the  normal  degree, 
while  the  bowels  are  often  constipated.  You  will  find,  when  you  are 
suffering  in  this  manner,  that  if  you  take  a  warm  bath  or  a  hot  air  or 
vapor  bath,  by  which  the  free  action  of  the  skin  will  be  excited,  the 
unpleasant  sensations  cease,  and  at  least  for  a  time  you  feel  very  much 
better.  You  may  even  experience  complete  relief.  If  you  take  a  few 
doses  of  Nitrate  of  Potash,  or  Bicarbonate  of  Potash,  or  Liquor  Am- 
»wnicc  Acetatis,  or  some  other  saline  which  acts  on  the  skin  and  kidneys, 
you  will  be  greatly  relieved. 

This  relief  is,  I  think,  consequent  upon  the  removal  of  certain  sub- 
stances from  the  blood  which  had  been  accumulating  in  that  fluid  to  its 


58  DRY  AND  MOIST  TONGUE. 

detriment,  and  which  as  they  circulated  caused  derangement  of  action 
in  many  tissues  and  organs  in  the  body.  I  shall  have  frequently  to 
direct  your  attention  to  the  general  and  often  widespread  changes  which 
result  from  deranged  actions  confined  to  very  limited  areas  of  tissue  or 
organ,  and  shall  show  that,  at  least  in  a  number  of  cases,  this  may  be 
explained  by  the  alterations  induced,  directly  or  indirectly,  in  the  char- 
acter and  composition  of  the  blood.  Hardly  any  of  the  ordinary 
physiological  changes  of  the  body  can  be  deranged  without  some 
alteration  taking  place  in  the  character  of  the  blood.  The  action  of 
the  digestive  organs  will  be  disturbed  at  once.,  and  of  this  we  shall  soon 
have  indications  in  the  loss  of  appetite  and  various  unpleasant  sensa- 
tions in  the  stomach,  as  well  as  by  the  altered  state  of  the  tongue. 

Of  Dry  and  Moist  States  of  the  Tongue. — One  of  the  commonest 
changes  observed  in  the  tongue  is  undue  dryness, — a  condition  which 
may  depend  upon  a  variety  of  circumstances.  The  moisture  of  the 
parts  within  the  mouth  varies  greatly,  and  even,  in  most  persons,  the 
mouth  is  not  equally  moist  at  all  periods  of  the  day  and  night.  The 
activity  of  the  process  of  secretion  varies  much  at  different  times;  the 
quantity  of  fluid  in  the  interstices  of  a  thick  tissue  like  the  skin  or  the 
dorsal  surface  of  the  tongue  is  by  no  means  always  the  same,  and  varies 
with  every  change  in  the  tension  of  the  walls  of  the  capillaries,  the 
pressure  of  the  circulation,  the  activity  of  the  lymphatics,  and  a  number 
of  other  circumstances.  Lastly,  it  is  obvious  that  the  varying  rate  of 
evaporation  from  the  mouth  and  nasal  passages  will  alone  cause  altera- 
tions in  the  tongue  as  regards  its  moisture. 

The  dryness  of  the  dorsal  surface  of  the  tongue,  a  change  which  is 
not  uncommon  in  many  forms  of  disease,  cannot  be  attributed  only  to 
changes  taking  place  upon  the  surface  of  the  mucous  membrane,  for  the 
secretion  of  fluid  by  the  glands  beneath  might  entirely  compensate,  or 
more  than  compensate,  for  the  loss  of  fluid  by  evaporation.  In  many 
cases  the  dryness  seems  to  be  due  to  alterations  which  take  place 
beneath  the  mucous  membrane  affecting  the  nutrition  of  the  deep  cells 
of  the  cuticular  coverings  of  the  papilla?,  and  in  part  to  the  change  in  the 
composition  of  the  blood  itself  and  an  altered  state  of  the  blood  dis- 
tribution, as  determined  by  dilatation  of  the  little  arteries,  consequent 
upon  relaxation  of  the  circular  muscular  fibres,  occasioned  by  change  in 
some  part,  peripheral  orcentral,  of  thenerve  apparatus  which  governs  their 
calibre.  In  ordinary  health  the  moist  condition  of  the  tongue  is  due  partly 
to  the  transudation  of  fluid 'through  the  walls  of  the  vessels  towards  the 
epithelial  and  other  tissues,  and  partly  to  the  presence  of  fluids  secreted 
in  varying  quantities  and  poured  into  the  cavity  of  the  mouth,  particu- 
larly the  saliva.  The  surface  of  the  tongue  and  inside  of  the  mouth 
are  thus  kept  moist.  The  moisture  of  the  tongue  and  interior  of  the 
mouth  will,  however,  be  very  much  favored  if  the  air  we  breathe  is 


DRYNESS   OF  MOUTH  AND   TONGUE.  59 

moist,  while  in  the  opposite  state  of  things  the  tongue  will  become  more 
or  less  dry  from  evaporation.  Obviously  a  greater  amount  of  fluid  will 
be  required  to  maintain  the  mouth  in  a  moist  state  in  dry  than  in  damp 
weather.  The  quantity  of  vapor  communicated  to  the  expired  air 
which  traverses  the  cavity  of  the  mouth  is  liable  to  variations  according 
to  changes  which  occur  in  the  lungs  and  air  passages.  The  blood,  as 
it  traverses  the  capillaries  of  the  lungs  at  different  times,  contains  very 
different  quantities  of  fluid,  and  therefore  during  some  periods  much 
more  vapor  will  be  given  off  from  the  blood  to  the  air  about  to  be 
expired  than  at  -other  periods.  Not  only  so,  but  the  rate  of  exhalation 
of  watery  vapor  from  the  blood  is  influenced  by  a  number  of  complex 
conditions  which  are  continually  undergoing  change,  but  which  I  must 
not  attempt  to  consider  here.  Every  time  we  expire  through  the  open 
mouth,  the  air  laden  with  moisture  is  driven  over  the  mucous  mem- 
brane of  the  mouth  and  tongue.  However  dry  the  inspired  air  may  be, 
it  becomes  nearly  saturated  with  moisture  as  it  leaves  the  air-cells  of 
the  lungs.  This  damp  air  playing  over  surfaces  it  traverses  assists  in 
keeping  them  moist. 

The  mouth  and  tongue,  however,  may  readily  become  dry,  and  a 
very  unpleasant  state  of  things  will  be  experienced.  Those  who  have 
acquired  the  bad  habit  of  sleeping  with  the  mouth  wide  open  frequently 
suffer  from  the  derangement  in  question.  We  should  close  the  mouth 
before  falling  asleep,  and  during  sleep  we  should  breathe  freely  through 
the  nose.  In  cold  weather  it  is  important  that  the  cold  air  which  is 
inhaled  should  pass  over  the  surface  of  the  mucous  membrane  of  the 
nasal  passages,  in  order  that  it  may  be  warmed  before  it  reaches  the 
windpipe  and  lungs.  The  air  which  receives  a  supply  of  moisture  is 
better  adapted  for  the  further  complex  chemical  changes  effected  by 
respiration,  which  changes,  as  many  of  you  are  no  doubt  aware,  are  most 
actively  carried  on  during  the  period  of  sleep.  Always  advise  your 
patients  to  get  into  the  habit  of  keeping  the  mouth  closed  and  breathing 
through  the  nose,  not  only  during  sleep,  but  generally,  for,  especially  in 
cold  weather,  it  is  important  upon  many  grounds  that  the  inflowing  air 
should  take  this  circuitous  route  rather  than  the  more  direct  one  by  the 
mouth. 

As  soon  as  the  mucous  membrane  of  the  mouth  or  adjacent 
passages  gets  dry,  a  desire  for  fluid  will  be  experienced.  The  person 
longs  for  a  little  water,  and  when  he  gets  it  he  moves  it  about  in  all 
parts  of  the  mouth,  so  as  to  thoroughly  moisten  the  mucous  membrane ; 
but  this  operation  requires  to  be  very  frequently  repeated,  as  the  surface 
when  moistened  with  water  gets  dry  much  sooner  than  when  bathed 
with  the  natural  fluids  of  the  mouth.  In  many  cases  you  will  find 
glycerine  and  water,  in  the  proportion  of  one  part  to  five  or  six,  more 
effective  than  pure  water.  A  little  lemon-juice  may  be  added  to  make 


60  SALIVARY  SECRETION. 

the  mixture  more  palatable,  and  sometimes  you  will  find  that  linseed 
tea  with  glycerine  will  be  better  than  water. 

If  the  mouth  becomes  very  dry,  articulation  will  be  difficult  or  impos- 
sible. No  one  can  speak  properly  if  his  mouth  and  tongue  lose  their 
ordinary  moist  condition,  and  you  may  have  noticed  that  many  orators 
who  are  accustomed  to  address  audiences  for  a  considerable  period  of 
time  are  obliged  to  sip  water  every  now  and  then.  In  perfect  health 
the  quantity  of  saliva  that  flows  into  the  mouth  varies  remarkably  at 
different  times,  and  the  proportion  is  diminished  in  any  little  derange- 
ment of  the  system.  The  mouth  feels  more  or  less  dry  and  uncomfort- 
able until  the  free  secretion  of  the  salivary  fluid  is  resumed.  Some 
speakers  are  seen  to  take  a  few  drops  of  fluid  every  four  or  five  minutes, 
and  I  much  fear  that  in  some  of  these  cases  the  dry  state  of  the  mucous 
membrane  has  resulted  from  the  introduction  during  a  long  period  of 
time  of  too  much  alcohol  into  the  system,  a  practice  which  soon 
causes  most  important  changes  in  the  blood,  and  eventually  leads  to 
impairment  of  the  action  of  the  most  important  of  the  secreting 
glands. 

Of  Exciting  the  Flow  of  Saliva. — In  many  cases  in  which  the 
secretion  of  saliva  is  deficient,  the  increased  action  of  the  salivary 
glands  may  be  excited  in  a  very  simple  manner.  Anything  which 
promotes  the  flow  of  saliva,  and  induces  the  glands  of  the  mouth  to 
secrete  more  freely,  will,  to  some  extent,  relieve  a  dry  state  of  the  mouth 
and  tongue.  Commonly,  the  mere  irritation,  stimulation,  or  excitation 
of  the  sensitive  nerve-fibres  spread  out  beneath  the  epithelium  of  the 
mucous  membrane  of  the  mouth,  brought  about  by  the  contact  of 
some  pungent  or  acid  material,  is  sufficient  to  cause  a  very  free 
salivary  secretion.  A  small  piece  of  lemon  just  placed  in  the  mouth 
will  often  give  rise  to  a  very  free  flow  of  saliva ;  and  there  are  various 
pungent  materials  which  are  introduced  into  the  mouth  for  the  very 
purpose.  The  mere  moving  about  in  the  mouth  of  some  solid  body, 
such  as  a  smooth  pebble,  will,  through  reflex  action,  promote  the  secretion 
of  the  saliva.  The  pebble  acts  upon  the  nerves,  and  an  increased  flow 
of  saliva  follows.  This  is  owing  not  only  to  the  expulsion  of  the  secre- 
tion already  formed,  but  to  increased  secretion  of  salivary  fluid  by  the 
gland-cells. 

Sialogogues. — We  have  many  remedies  which  belong  to  the  class  of 
Sialogogues  (tuaxoi/,  saliva,  and  ayw,  I  expel).  Horse-radish, — Mezereum, 
—  Ginger, — Pyrethrum,  the  root  of  Anacyclus  Pyrethrum,  the  old  Pelle- 
tory  of  Spain,  are  examples  of  well-known  sialogogues.  But  there  is 
one  better  known  to  most  of  you,  though  its  use  as  a  sialogogue  is  in 
these  days  almost  entirely  limited  to  some  of  the  nautical  people — I 
mean  tobacco,  which  if  used  at  all  should  be  smoked,  not  chewed,  and 
smoked  only  in  moderation,  and  in  the  open  air. 


SIALOGOGUES.  6 1 

Certain  salts  also  excite  the  secretion  of  the  salivary  glands. 
Chlorate  of  Potash  (Dose,  twenty  grains  in  water)  and  Nitrate  of  Potash 
{Dose,  five  to  twenty  grains  dissolved  in  a  wineglassful  of  water)  are 
among  the  best.  Sucking  fused  nitre  (nitre  balls)  is  an  old  and  very 
favorite  treatment  for  many  slight  ailments. 

You  may  now  get  Nitrate  of  Potash,  generally  known  as  Nitre, 
Chlorate  of  Potash,  Bicarbonate  of  Potash  and  Soda,  and  a  number 
of  other  useful  saline  remedies,  compressed  into  small  lozenges  or 
pilules  containing  five  grains  each.  One  or  two  may  be  allowed 
to  slowly  dissolve  in  the  mouth  three  or  four  times  a  day,  half  an 
hour  or  more  after  a  meal,  and  you  will  find  they  will  cause  a 
very  free  flow  of  saliva.  When  the  mouth  becomes  very  dry  at  night, 
it  is  a  good  plan  for  the  sufferer  to  sip  now  and  then  a  little  cold 
Linseed  tea  (one  tablespoonful  of  Linseed  infused  with  a  pint  of  boiling 
water ;  when  cold  the  seeds  may  be  strained  off  and  a  little  sugar 
added).  Or  the  viscid  fluid  may  be  flavored  with  lemon  juice,  and 
sweetened  with  glycerine  in  cases  in  which  it  is  not  desirable  to  give 
sugar.  Or,  a  mixture  of  the  latter  with  water, — one  of  glycerine  to 
five  or  six  of  water  may  be  used. 

But  the  most  important  and  most  potent  of  all  our  medicines  used 
for  increasing  the  action  of  the  salivary,  and  most  if  not  all  other  glands 
in  the  body,  is  Mercury.  You  will  find  when  you  have  to  prescribe  for 
a  dry,  uncomfortable  state  of  the  mouth,  that  if  you  give  only  half  a 
grain  of  calomel,  or  even  considerably  less  than  this,  within  five  or  six 
hours  a  free  secretion  of  the  saliva  into  the  mouth  will  occur,  and  the 
mucous  membrane  of  the  mouth,  fauces,  and  neighboring  parts  will 
become  moist  and  more  comfortable.  All  the  little  labial  and  buccal 
glands  will  secrete  more  freely.  Instead  of  Calomel,  you  may  give  one 
or  two  grains  of  blue  pill  or  gray  powder.  The  last  (Hydrargyrum  cum 
Creta)  is  the  mildest,  and  perhaps  the  best,  of  all  the  mercurial  prepara- 
tions we  use.  In  children's  ailments  it  is  one  of  the  most  efficient 
remedies  handed  down  to  us.  In  the  days  of  my  apprenticeship,  we 
used  to  keep  equal  parts  of  powdered  Rhubarb  and  Hydrargyrum  cum 
Cretd  already  mixed,  and  gave  from  one  to  six  grains  of  the  mixture  to 
children,  according  to  age.  I  continue  to  use  this  most  useful  prescrip- 
tion. The  only  objection  is  its  nastiness,  even  in  jam  ;  but  for  older 
children  and  adults  the  powder  may  be  made  into  pills  with  a  little 
Extract  of  Henbane. 

White  Moist  Furred  Tongue. — In  some  conditions  the  tongue  pre- 
sents a  very  peculiar  appearance,  being  very  white  in  consequence  of 
the  accumulation  of  a  quantity  of  soft  moist  epithelium  on  its  surface, 
with  mucus  and  secretions  from  some  small  glands,  with  multitudes  of 
bacteria,  fungi,  and  the  debris  of  food.  This  state  of  tongue  is  seen 
in  its  most  remarkable  degree  of  manifestation  in  acute  rheumatism. 
6 


62  PALE    TONGUE. 

Unfortunately,  we  have  many  opportunities  of  studying  the  tongue  in 
this  serious  malady  in  the  wards  of  our  hospital,  which  often  contains 
several  well-marked  cases  of  the  disease. 

I  do  not  know  anything  you  can  do  in  the  hospital  tolerably  early  in 
your  student  days,  that  will  be  of  more  real  use  to  you  afterwards,  than 
making  observations  upon  the  characters  of  the  tongue  in  different 
forms  of  disease.  I  strongly  advise  you,  with  the  permission  of  the 
house  physician,  to  go  into  the  wards  when  he  makes  his  visits,  and 
institute  a  careful  examination  of  the  tongue  in  several  well-marked 
cases  of  disease.  Describe  what  you  see,  and  repeat  the  observations 
on  each  case  every  day  or  every  other  day.  It  is  better  not  to  under- 
take more  than  two  or  three  cases  at  one  time.  Make  microscopic 
examinations  of  the  fur  every  now  and  then,  and  keep  careful  records 
and  drawings  of  the  results.  From  time  to  time  you  will  notice  how 
frequently  improvement  in  the  state  of  the  patient  coincides  with,  or  is 
just  preceded  by,  satisfactory  changes  in  the  state  of  the  tongue.  Of 
course  you  will  meet  with  exceptions,  and  you  will  easily  find  cases  which 
might  be  adduced  in  favor  of  the  opinion  that  the  appearances  of  the 
tongue  are  so  variable  and  so  uncertain  that  nothing  of  importance 
clinically  is  to  be  gained  by  taking  note  of  the  state  of  the  organ.  To 
rely  exclusively  on  changes  in  the  tongue  would  undoubtedly  be  unwise 
and  misleading,  but  I  think  not  more  so  than  it  would  be  to  observe 
exclusively  other  individual  signs  and  symptoms  of  disease.  We  do 
gain  important  information  from  the  tongue,  and  I  strongly  advise  you 
to  study  the  changes  which  occur  in  its  appearances. 

Pale  Tongue,  Ancemia  (a,  priv.,  afyta,  blood,  literally  bloodlessness). 
In  ansemia  the  blood  is  poor  and  defective  in  red  blood-corpuscles.  In 
anczmic  persons,  and  in  those  suffering  from  various  forms  of  disturbed 
digestion,  the  tongue  is  flabby,  the  vessels  being  imperfectly  filled  with 
blood,  and  the  blood  itself  poor  in  red  corpuscles.  The  dorsum  of  the 
tongue  appears  pallid,  and  a  quantity  of  moist  epithelium  adheres  to 
its  surface.  The  tongue  itself  is  sometimes  visibly  larger,  swollen  or 
sodden,  cedematous  (oiS^a,  from  otSao,  to  swell),  as  well  as  soft  and 
flabby.  The  edges  are  much  indented  and  marked  with  impressions 
of  the  teeth.  This  state  of  tongue  improves  under  the  influence  of 
quinine  and  other  tonics,  and  other  remedies  which  improve  the  diges- 
tive power  of  the  stomach. 

In  Slight  Chronic  Rheumatism  (Rheuma,  jjlw,  to  flow)  the  tongue  is 
frequently  white,  covered  with  what  we  call  a  thick,  blankety  fur.  The 
white  furred  tongue  is  more  moist  than  is  the  organ  in  the  normal 
healthy  state ;  its  epithelium  is  abundant  and  sodden,  and  everywhere 
invaded  by  fungi.  Numerous  low  organisms  are  actually  growing  and 
multiplying  very  rapidly  in  the  moist,  soft,  imperfectly-formed  epithelium 
which  continues  to  be  developed  and  to  accumulate  while  the  rheuma- 


BRIGHT  RED   TONGUE.  63 

tic  state  lasts.  .Various  organic  matters  also  collect,  and  decomposition 
may  take  place  in  the  spongy  mass,  which  is  formed  in  such  great 
abundance.  The  various  fluids  of  the  mouth  also  contribute  to  increase 
the  thickness  of  the  white  fur  so  characteristic  of  the  disease. 

In  many  temporary  derangements  of  the  stomach  and  bowels  we  also 
find  this  moist  furred  condition  of  the  tongue,  and  it  may  last  for  a  few 
days  at  a  time.  The  tongue  of  inveterate  smokers  is  generally  white  and 
dirty.  Some  persons  constantly  have  a  foul  tongue,  although  they 
are  nevertheless  in  good  health.  A  constantly  dirty  tongue,  like  some 
other  departures  from  the  normal  state,  is  not  incompatible  with  con- 
siderable vigor,  good  working  power,  and  longevity. 

Bright  Red  Tongue. — In  striking  contrast  with  the  white  blankety 
tongue  is  the  red  tongue,  which  is  met  with  in  certain  forms  of  fever,  the 
surface  being  smooth,  of  a  bright  red  color,  sometimes  appearing  raw, 
and  not  unfrequently  being  dry  and  glazed.  The  red  tongue  is  often 
seen  in  scarlet-fever.  In  the  early  stage  of  the  disease  the  tongue 
is  often  furred,  and  the  red  fungi  form  papillae  are  seen  to  project 
through  the  adherent  epithelium,  and  appear  as  bright  red  spots.  But 
in  a  few  days  the  superficial  layers  of  epithelium  of  the  tongue  and  of 
the  lining  membrane  of  the  mouth  and  fauces  are  detached,  desquamate 
(de,  from,  squama,  a  scale),  and  then  the  whole  surface  of  the  tongue  is 
red.  The  fungiform  papillae  are  swollen  and  the  vessels  much  dis- 
tended, the  surface  more  or  less  uneven,  and  we  have  the  appearance 
somewhat  resembling  that  of  a  strawberry — hence,  the  strawberry  tongue. 

The  smoothness  and  redness  of  the  tongue  last  for  some  time,  for 
the  old  cells  of  epithelium  having  been  completely  detached,  some  time 
must  elapse  before  the  new  cells  have  sufficiently  accumulated  to  pre- 
vent the  red  color  of  the  blood  being  so  distinctly  seen  in  the  vessels 
beneath.  The  raw,  beefy  character  of  the  tongue  is  also  observed 
towards  the  close  of  many  exhausting  diseases,  as  phthisis  (00t»<«,  to 
corrupt),  and  some  forms  of  pyaemia.  Aphthous  sores  also  form  some- 
times in  conjunction  with  this  state  of  the  tongue,  and  must  be  treated 
as  described  in  page  66. 

The  Dry  Brown  Tongue. — Strictly  speaking,  the  dry  brown  tongue 
is  hardly  ever  seen  in  slight  ailments,  and  I  shall  only  say  a  few  words 
about  it  here  for  convenience'  sake.  Do  not  forget  that  a  state  of  tongue 
somewhat  resembling  it  may  result  from  sucking  liquorice,  black 
currants,  or  black  cherries ;  and  other  dark  fruits  may  produce  tem- 
porary staining  of  the  tongue.  These  give  to  it  a  very  peculiar  ap- 
pearance which  you  ought  to  be  able  to  recognize  at  once,  and  it  is  well 
also  to  bear  in  mind  that  the  juices  of  some  fruits,  or  other  fluids  having 
the  property  of  staining  the  tongue  or  skin,  are  sometimes  applied,  in 
order  to  puzzle  us. 

In  typhus  and  typhoid  fever,  and  many  other  low  conditions,  the 


64  DRY  TONGUE  AND  MOUTH:    TREATMENT. 

tongue  may  become  brown  or  more  or  less  black,  owing  to  changes 
occurring  in  the  epithelium,  which,  with  mucus  and  secretions  from 
various  glands,  has  accumulated  upon  its  surface  and  has  got 
dry.  If  the  feverish  condition  reaches  any  considerable  degree  of  in- 
tensity, as  I  have  already  told  you,  the  moist  surfaces  about  the  mouth 
soon  become  very  dry  and  cease  to  secrete.  They  are  no  longer  bathed 
with  healthy  moisture,  the  mucus  is  no  longer  formed,  and  the  secretion 
of  the  salivary  and  other  glands  is  diminished  to  such  an  extent  as  to 
render  the  process  of  deglutition  (the  swallowing  of  the  food)  extremely 
difficult.  This  is  one  of  the  reasons  why  we  give  patients  suffering  from 
fever,  milk  and  beef-tea,  and  put  them  on  slop  diet.  All  the  nutrient 
matter  required  should  be  introduced  in  actual  solution,  or  in  a  very 
moist  state,  as  in  the  form  of  pap  ;  or  you  may  have  finely  divided  solid 
matter  suspended  in  beef-tea,  soup,  or  milk,  and  thus  much  nutritious 
matter  may  be  given  in  cases  where  it  is  absolutely  required  to  support 
life.  In  milk,  as  you  are  probably  aware,  some  nutrient  materials  are 
dissolved,  while  fatty  matter  exists  as  very  minute  globules  suspended  in 
the  fluid,  and  therefore  in  a  state  in  which  it  is  very  easily  absorbed  into 
the  blood. 

In  many  cases  great  relief  will  be  afforded  if  the  nurse  will  occa- 
sionally paint,  as  it  were,  the  dry  mucous  membrane  of  the  tongue  and 
mouth  with  a  little  weak  glycerine  and  water  (one  part  to  nine  or  ten  of 
water)  with  a  camel-hair  brush.  This  is  very  necessary  in  some  severe 
forms  of  fever  in  which  the  tongue  and  mouth  get  very  dry  and  painful. 
After  the  tongue  has  been  dry  for  several  days,  it  is  not  unusual  for 
deep  fissures  to  form  upon  its  surface,  and  these  fissures  sometimes  go 
quite  through  the  mucous  membrane,  and  even  reach  the  vessels  and 
nerve-fibres  in  its  substance.  Escape  of  blood  (hasmorrhage)  frequently 
occurs,  and  the  blood  accumulates  and  helps  to  form  the  dry  brown 
matter  which  adheres  to  the  tongue.  Sometimes  much  of  the 
haemoglobin  of  the  blood  is  disintegrated  while  the  blood  circulates, 
and  may  make  its  way  through  the  capillaries  without  rupture;  but 
more  generally  the  blood  escapes  from  the  capillaries  in  the  usual 
manner,  in  consequence  of  their  over-distention  and  the  formation  of 
longitudinal  rents  or  fissures  in  their  walls.  Unless  sensation  is  pre- 
viously numbed  by  the  presence  of  morbid  substances  in  the  blood, 
the  occurrence  of  the  fissures  is  associated  with  much  pain,  discomfort, 
and  distress. 

The  blood  from  the  vessels  and  the  viscid  mucus  which  collects 
upon  the  tongue  and  lips,  together  form  dark  brown  or  black  flaky 
masses  (sordes,  from  the  Latin,  sordes,  dirt,  filth),  which  accumulate 
about  the  mouth  and  often  firmly  adhere  to  the  surface  of  the  teeth. 
These  may  sometimes  be  pulled  off,  but  generally  leave  a  raw  and  sore 
surface  beneath. 


HEMORRHAGE:  NATURE.  6$ 

The  dry  brown  tongue  passes  by  gradations  into  the  black  tongue, 
characteristic  of  some  of  the  very  worst  forms  of  fevers  which  occurred 
in  former  days,  and  which  are  even  now  occasionally  met  with  in  the 
East.  As  the  severity  pf  the  feverish  state  passes  off,  the  tongue  begins 
to  clean,  usually  first  at  the  edges.  This  "cleaning"  results  from  the 
growth  of  new  epithelium  on  the  deep  surface,  and  the  detachment  of 
the  old  cells  with  mucus,  fungus  growths,  particles  of  food,  and  probably 
a  little  blood,  which  have  been  accumulating  and  have  adhered  to  the 
surface  during  the  illness.  As  convalescence  approaches,  all  this  is  cast 
off.  To  prevent  this  altered  and  partly  decomposed  organic  matter, 
debris,  etc.,  being  swallowed,  the  mouth  should  be  frequently  rinsed 
out  with  Candy1 's  fluid  and  water  (one  teaspoonful  to  a  tumbler  of 
water),  or  a  very  weak  Solution  of  Sulphurous  acid  (one  part  of  the 
Sulphurous  acid,  Acidum  Sulphurosum  of  the  Pharmacopoeia,  to  five  or 
six  parts  of  water),  or  of  Hyposulphite  of  Soda  (five  grains  to  an  ounce 
of  water). 

Haemorrhage. — Just  now  I  used  the  word  haemorrhage,  and  as  this 
was,  I  think,  the  first  time  I  have  had  to  employ  the  term,  it  is  desirable 
that  I  should  explain  its  meaning,  and  tell  you  exactly  what  happens 
when  hcemorrhage  takes  place.  The  word  is  derived  from  two  Greek 
words,  ai^ia,  "blood,"  and  '^yvv^,  "to  break  forth."  Haemorrhage 
means,  therefore,  a  breaking  forth  of  blood.  In  former  days  we  used  to 
be  told  that  there  was  such  a  thing  as  the  passage  of  blood  corpuscles 
through  closed  membrane,  through  the  walls  of  vessels,  in  some 
mysterious  manner,  without  any  rupture  or  solution  of  continuity  in  their 
walls.  This  was  called  hcemorrhage  by  exhalation,  and  in  my' student 
days  the  opinion  was  still  entertained  that  red  blood  corpuscles  might 
traverse  a  capillary  wall  by  "exhalation."  At  an  earlier  period,  the 
capillaries  used  to  be  spoken  of  as  exhalant  vessels,  and  their  function 
was  regarded  by  some  as  opposed  to  that  of  the  absorbents. 

Under  certain  circumstances  blood  corpuscles  may  pass  through  the 
thin  walls  of  capillary  vessels  without  the  vessels  being  destroyed  or 
permanently  damaged.  In  all  cases,  however,  an  opening,  it  may 
be  temporary  only,  in  the  vascular  wall  does  exist.  The  capillary  is  not 
actually  torn  across,  but  when  it  becomes  much  distended  by  the 
accumulation  of  blood  within  it,  the  thin  vascular  walls  are  stretched 
and  rendered  very  thin.  Longitudinal  rents  or  fissures  result,  through 
which  the  blood  corpuscles,  a  few  at  a  time,  easily  escape.  When  the 
pressure  is  relieved,  the  elastic  wall  of  the  vessel  will  contract,  and  the 
fissures  close  up,  the  capillary  transmitting  the  blood  as  freely  as  it  did 
before. 

The  term  Hcemorrhage,  then,  is  strictly  correct,  and  always  means 
the  breaking  forth  of  blood  from  a  vessel,  large  or  small. 

Chronic  Cracks  and  Fissures  of  the  Tongue. — This  state  of  tongue 
6*  E 


66  OF  THE    USE    OF  IODIDE    OF  POTASSIUM. 

is  very  common  in  persons  who  have  long  suffered  from  weak  digestion. 
The  tongue  is  generally  rather  pale,  quite  moist,  and  from  time  to  time 
becomes  covered  with  white  fur,  which  is  often  distributed  in  patches. 
The  cracks  are  usually  rather  deep,  very  irregular  in  arrangement,  and 
differ  much  in  number  in  different  cases.  For  the  most  part  they  are 
permanent,  but  occasionally  new  ones  form  and  the  older  ones  increase 
in  depth.  The  papillae  at  the  edges  of  the  fissures  occasionally  become 
sore.  Aphthous  patches  of  irregular  shapes  may  appear  and  increase  in 
size,  extending  often  to  the  bottom  of  the  fissures,  and  sometimes  the 
tongue  becomes  so  sore  that  eating  solid  food  is  a  painful  process.  The 
cracks  may  go  on  separating  until  a  raw  surface  is  exposed  at  the  bottom. 
This  is  often  exquisitely  painful ;  and  if  any  alcohol,  pepper,  or  salt 
substance  is  taken,  the  almost  bare  nerve  fibres  exposed  in  the  fissures 
are  instantly  affected.  Not  unfrequently  in  such  cases  the  pain  and  dis- 
comfort are  so  great  that  the  patient  is  deterred  from  eating,  and  in  con- 
sequence the  general  health  suffers.  A  moderate  degree  of  the  con- 
dition of  tongue  referred  to  is  extremely  common.  It  does  not  usually 
interfere  with  longevity  or  predispose  to  any  more  serious  derangements. 
Those  who  suffer  in  this  way  are  obliged  to  be  very  careful  in  diet  and 
ought  to  live  very  moderately.  If  they  exceed  in  any  way,  digestion 
becomes  deranged,  the  tongue  gets  foul  and  very  sore,  and  some  days 
must  pass  before  the  usual  state  of  health  returns.  In  such  cases  the 
bowels  are  sluggish,  but  you  will  generally  find  that  mild  purgatives  only 
in  small  doses  can  be  borne.  Three  or  four  grains  of  compound  rhubarb 
pill,  two  or  three  nights  running,  with  perhaps  a  little  effervescing 
citrate  of  ammonia,  soda  or  potash,  or  some  such  simple  saline,  three  or 
four  times  daily,  will  be  of  use,  and  expedite  the  return  of  the  normal 
state.  Carbolic  acid  lotion  (one  part  to  one  hundred  of  water)  is  also 
a  good  application,  especially  if  the  fissures  are  associated  with  the 
presence  of  aphthous  spots,  with  vegetable  growths  on  the  surface,  but 
the  lotion  is  not  a  pleasant  one  to  use.  See  also  page  71. 

There  is,  however,  another  form  of  cracked  tongue  common  enough 
and  very  chronic,  which  is  not  to  be  cured  in  this  simple  manner. 
There  are  cracks  and  fissures  here  and  there,  but  in  some  situations  the 
surface  is  too  smooth.  The  appearance  is  such  as  to  lead  one  to  think 
that,  in  the  course  of  very  slow  pathological  changes  many  of  the 
papillae  have  undergone  change,  and  have  at  last  wasted  and  dis- 
appeared, just  as  the  villi  of  the  small  intestines  do  in  certain  forms  of 
disease. 

The  state  of  tongue  which  I  am  considering  may  last  for  years, 
getting  better  and  worse  many  times.  It  is  usually  relieved,  and  in  not 
a  few  cases  cured,  by  Iodide  of  Potassium.  The  remedy  must  be  taken 
for  two  or  three  or  more  weeks  at  a  time,  then  stopped  for  a  short 
period,  and  resumed  again.  You  may  begin  with  two  grains,  and 


CHANGES  IN  MOUTH  AND  FAUCES.  6/ 

gradually  increase  the  dose  to  five  or  six  grains  three  times  daily,  and 
it  is  a  point  to  give  ft  dissolved  in  as  much  as  half  a  pint  of  water. 

Some  cases  improve  rapidly  on  Iodide  of  Mercury.  You  may  order 
from  the  thirty-second  to  the  sixteenth  of  a  grain  of  the  Perchloride  of 
Mercury,  that  is,  from  thirty  to  sixty  drops  of  the  Liquor  Hydrargyri 
Perchloridi,  with  five  grains  of  Iodide  of  Potassium,  and  a  little  Syrup  of 
Ginger,  and  perhaps  twenty  minims  of  Battley' s  Liquor  Cinchona,  in  four 
ounces  of  water,  an  hour  after  food,  twice  or  three  times  a  day,  for  two 
or  three  weeks  at  a  time.  These  cases,  and  especially  if  they  are  cured 
by  the  medicine  I  have  recommended,  are  generally  considered  to 
result  from  syphilis,  but  I  feel  confident  that  all  are  not  of  this  nature. 
It  is  a  grave  mistake  to  suppose  that  everything  cured  by  mercury  and 
iodide  of  potassium,  or  some  other  iodide,  must  be  syphilitic  in  its 
nature  and  origin.  These  remedies  are  most  useful  in  the  treatment  of 
many  conditions  which  have  nothing  whatever  to  do  with  syphilis. 
Some  who  read  these  words  will,  however,  assert  that  I  am  mistaken,  and 
that  in  cases  in  which  the  patient  had  never  had  an  attack  of  syphilis, 
the  poison  must  have  been  introduced  into  the  organism  in  some 
obscure  and  unknown  manner,  or  that  it  got  into  the  organism  through 
its  predecessors,  one  or  more  generations  back.  This  is  a  mere  dictum. 
It  cannot  be  disproved,  but  it  rests  on  no  sound  foundation  of  fact  or 
observation,  and  I  attach  little  importance  to  such  assertions  when  they 
rest  on  authority  only. 

Changes  in  the  Mucous  Membrane  of  the  Mouth  and  Fauces. — 
Associated  with  the  changes  taking  place  in  the^  epithelial  surface  of  the 
back  of  the  tongue,  we  have  in  many  cases,  also,  corresponding  changes 
in  the  mucous  membrane  of  the  mouth,  the  palate,  the  fauces,  and  the 
throat.  The  mucous  membrane  of  all  these  parts  is  continuous,  and 
no  wonder  the  different  sections  are  sometimes  affected  in  the  same 
manner.  The  action,  also,  not  uncommonly  extends  downward  through 
the  narrow  chink  of  the  Glottis  (yXuirrct,  the  tongue)  into  the  Larynx 
(Aa'puyl,  the  larynx)  and  wind-pipe,  or  trachea  (rpazvj,  rough).  The 
voice  may  become  hoarse  in  consequence  of  the  mucous  membrane 
being  swollen,  dry,  and  otherwise  altered.  Not  unfrequently  this 
dryness  extends  to  the  posterior  nares,  and  affects  the  mucous  membrane 
at  the  back  of  the  nose,  giving  rise  to  a  very  painful  sensation,  a  slight 
degree  of  which  most  have  experienced  when  an  ordinary  cold  is  about 
to  come  on. 

If  you  look  in  the  looking-glass  at  the  back  part  of  the  widely  opened 
mouth,  when  a  cold  is  coming  on,  you  may  see  the  mucous  membrane 
of  a  darker  red  than  usual,  and  here  and  there  it  may  appear  glazed  and 
dry.  Not  only  so,  but  if  you  try  a  simple  experiment  you  will  discover 
that  an  important  change  has  taken  place  in  the  sensitiveness  of  the 


68  INHALERS.    BRONCHITIS  KETTLE. 

surface  of  the  delicate  mucous  membrane  of  the  soft  palate.  In  health 
the  slightest  touch  will  excite  movements  of  deglutition  by  reflex  action, 
but  when  the  membrane  is  dry  and  sore,  there  is  no  such  sudden 
response,  and  contraction  of  the  pharyngeal  muscles  ($dpvyt,  the  throat) 
follows  very  slowly,  or  does  not  occur  at  all.  You  may  touch  the  palate 
firmly  without  any  effort  to  swallow  being  excited.  This  benumbed 
state  of  the  highly  sensitive  surface  generally  is  only  temporary,  and 
consequent  upon  the  changes  which  have  occurred  just  beneath  the 
epithelium,  where  extremely  delicate  afferent  nerve  fibrils  are  distributed 
in  immense  numbers,  but  the  condition  may  occur  frequently,  and  some 
persons  are  hardly  ever  free  from  some  slight  derangement  of  the 
mucous  membrane  of  the  soft  palate,  fauces,  and  upper  part  of  the 
Pharynx  ($apry(-,  the  throat).  In  the  treatment  of  this  state  of 
things,  inhalation  of  steam  simple,  or  with  a  little  ammonia  or  camphor, 
is  often  of  use.  Simple  forms  of  apparatus  are  now  made  for  the  pur- 
pose. 

Inhalers  are  now  largely  sold.  Many  are  made  of  china,  .and  are  so 
arranged,  that  various  volatile  substances  may  be  very  easily  inhaled 
with  the  steam  of  warm  water.  The  latter  alone  often  affords  great 
relief  in  irritable  states  of  the  mucous  membrane  of  the  throat  and  air 
passages. 

Bronchitis  Kettle. — The  air  of  the  sick-room  maybe  rendered  moist 
by  arranging  an  ordinary  kettle  in  such  a  manner  that  the  steam  comes 
direct  from  the  kettle-mouth  into  the  room,  instead  of  going  up  the 
chimney.  The  spoufof  the  kettle  maybe  lengthened  by  adding  a  foot 
or  more  of  tin  tube,  or  the  special  bronchitis  kettle  made  for  the  pur- 
pose may  be  used. 

In  derangements  of  the  kind,  the  application  of  astringent  substances 
to  the  palate  and  fauces  often  affords  relief.  You  may  apply  with  a 
large  camel-hair  brush  a  little  of  the  Glycerine  of  Tannic  Acid,  the  Glyce- 
rinum  Acidi  Ttinnici,  or  a  solution  of  Nitrate  of  Silver  (five  to  ten  grains 
to  the  ounce  of  distilled  water),  three  or  four  times  daily.  A  few 
minutes  after  application  the  mouth  should  be  gargled  out  with  cold 
water  or  salt  and  water  (one  teaspoonful  or  more  to  half  a  pint) ;  but 
the  best  plan  of  treating  such  affections,  especially  if  they  are  chronic, 
is  the  direct  application  of  the  astringent  or  other  solution,  in  the  form 
of  spray,  as  I  will  now  describe. 

Of  the  Use  of  Spray. — Of  late  years  very  many  remedies  have  been 
applied  to  parts  about  the  mouth  in  the  form  of  spray,  and  great  advan- 
tage has  resulted.  The  practice  was  first  employed  in  the  treatment  of 
diseases  of  the  larynx,  and  many  very  ingenious  instruments  have  been 
invented  for  the  purpose  of  obtaining  a  cloud  of  watery  vapor  in  a  very 
minute  state  of  division.  Spray  producers  have  of  late  been  very  much 


OF  THE    USE   OF  "SPRAY."  69 

simplified  in  structure,  as  well  as  rendered  much  more  perfect.  There 
are  two  principal  forms  of  apparatus.  One  in  which  the  "spray" 
consists  of  high  pressure  steam,  a  stream  of  water  with  the  required  sub- 
stances dissolved  in  it,  being  minutely  divided  into  spray  by  the  steam 
as  it  issues  from  a  tube  communicating  with  a  reservoir.  The  steam  is 
obtained  by  boiling  water  in  a  strong  copper  boiler  specially  made  for 
the  purpose  and  heated  by  a  spirit-lamp.  In  the  other,  the  requisite 
degree  of  pressure  required  for  sufficiently  comminuting  the  liquid  to  be 
converted  into  spray  is  obtained  by  a  little  india-rubber  ball  bellows. 
Both  forms  may  now  be  obtained  of  the  surgical  instrument  makers  for 
a  few  shillings,  and  are  well  adapted  for  use  in  the  treatment  of  affections 
of  the  mucous  membrane  of  the  mouth,  throat,  nose,  and  larynx.  The 
solution  containing  the  material  to  be  projected  against  the  mucous 
membrane  may  be  much  stronger  if  the  steam  spray  producer  be  used 
than  if  the  air  instrument  be  selected,  because,  in  the  first  case,  the 
solution  converted  into  spray  is  diluted  in  strength  by  the  steam  which 
is  used.  Some  of  the  best  spray  producers  are  those  used  by  Professor 
Lister  in  surgical  operations. 

In  cases  of  dryness  of  the  mouth,  tongue,  and  throat,  water  alone 
may  be  used  in  the  form  of  spray,  or  water  with  the  addition  of  one- 
tenth  part  of  pure  glycerine.  Alum  spray  solution  is  a  powerful 
astringent.  Ten  grains  of  Alum  to  the  ounce  of  water  is  a  good  pro- 
portion. The  same  quantity  of  Tannic  Acid  may  also  be  tried.  The 
spray  solution  of  Carbolic  Acid  may  contain  two  grains  to  the  ounce  of 
water.  Of  Chloride  of  Sodium,  that  is  common  salt,  from  two  to  twenty 
grains  or  more  to  the  ounce  of  water.  Chlorate  of  Potash  five  to  fifteen 
grains  to  the  ounce.  Nitrate  of  Potash  solution  may  be  used  of  the  same 
strength.  The  spray  solution  of  Nitrate  of  Silver  should  contain  a  grain 
to  the  ounce  of  distilled  water. 

You  must  be  careful  to  filter  the  spray  solution  before  you  use  it,  and 
you  must  prevent  dust  from  getting  into  it,  as  the  fine  tube  of  the  spray 
producer  is  very  easily  obstructed  by  any  smalb  solid  particle,  and 
is  cleaned  with  difficulty.  I  find  it  a  good  plan  to  cover  the  end  of 
the  tube  which  dips  into  the  solution  with  a  piece  of  muslin,  which  may 
be  tied  round  it.  In  this  way  any  solid  particles  which  may  be  suspended 
in  the  fluid  will  be  entirely  prevented  from  entering  the  spray-tube  at  all. 
The  spray  instruments,  the  tubes  of  which  are  made  of  vulcanite,  and 
which  are  worked  by  the  hand,  answer  very  well  for  ordinary  purposes 
when  five  minutes'  application  two  or  three  times  a  day  is  sufficient,  but 
for  more  prolonged  use  a  good  steam  apparatus  is  the  best.  Simple 
spray  producers  worked  by  the  hand  can  be  readily  obtained.  I  think, 
as  time  goes  on,  we  shall  find  that  the  spray  method  is  well  adapted  for 
the  treatment  of  certain  forms  of  skin  disease,  and  many  other  cases  in 


7O  STEAM  SPRA  Y  PRODUCERS. 

which  it  is  not  used  at  present.  There  is  no  difficulty  whatever  in  the 
use  of  the  spray  producer,  and  the  patient  «an  be  easily  taught  to  use 
the  apparatus  himself.  For  some  time  past  I  have  had  a  large  spray 
producer  of  the  form  used  by  Professor  Lister  in  constant  use.  It 
answers  perfectly  for  many  purposes,  and  I  often  employ  it  for  disin- 
fecting persons,  clothes,  or  rooms.  When  attending  any  case  of  con- 
tagious disease,  I  can  expose  every  part  of  my  clothes,  as  well  as  my 
hair  and  hands,  to  the  action  of  a  twenty  or  thirty  per  cent,  solution 
of  carbolic  acid.  So  quickly  can  the  steam  be  generated  that  the 
whole  process  does  not  take  more  than  ten  minutes  or  a  quarter  of  an 
hour. 

Metallic  and  other  Tastes  in  the  Mouth. — Patients  not  unfrequently 
complain  of  very  peculiar  tastes  in  the  mouth,  described  as  metallic,  salt, 
acid,  sweet,  bitter,  and  even  faecal  (Faex,  dregs.)  The  odorous  matter 
of  some  putrid  smells  is  unquestionably  sometimes  absorbed  into  the 
blood  from  the  inspired  air,  and  afterwards  exhaled,  the  smell  and  taste 
of  the  breath  remaining  for  many  hours  after  the  individual  has  left  the 
neighborhood  of  the  odoriferous  matter.  In  various  derangements  of 
the  stomach  the  most  peculiar  tastes  are  experienced,  and  by  patients 
are  compared  to  the  flavor  of  rancid  butter,  valerian,  vinegar,  and 
many  other  things.  Generally  speaking,  the  symptoms  complained  of 
may  be  relieved  by  exciting  the  excreting  organs. 

Purgatives,  especially  small  doses  of  Calomel  or  Gray  Powder  (one  to 
three  grains)  repeated  every  third  or  fourth  night  for  a  fortnight  or 
longer,  usually  afford- relief.  Exercise,  free  perspiration  in  a  warm 
bath,  Diuretics  and  Siidorifics  are  also  useful. 

Thrush,  Aphthse, — Sores  and  Ulcers  in  the  Mouth. — Sores  of  the 
mucous  membrane  of  the  mouth  are  exceedingly  common.  These 
superficial  sores  are  spoken  of  as  Aphtha,  from  the  Greek  urtrw,  I 
inflame.  The  derivation  is  not  a  very  good  one,  for,  although  no  doubt 
the  aphthous  spots  are  associated  with  inflammation,  they  are  not  caused 
by  this  process.  The  meaning  of  this,  like  those  of  many  other  scientific 
terms,  has  changed  as  our  knowledge  has  advanced.  Aphthae  are  little 
superficial  ulcer-like  depressions,  sometimes  with  infiltration  and  con- 
sequent thickening  of  the  tissues  around,  which  form  upon  the  surface 
of  the  mucous  membrane.  Sometimes  the  epithelium  only  seems  to  be 
affected,  but  more  often  the  sore  extends  deeper,  and  damages  the 
structure  of  the  mucous  membrane  itself.  Aphthae  are  extremely 
common  in  weak,  ill-nourished  infants,  but  are  not  unfrequently  met 
with  at  all  ages.  In  advanced  age  the  disease  occurs,  especially  in  • 
those  who  have  suffered  from  prolonged  exhausting  maladies.  In 
various  forms  of  chronic  phthisis,  and  in  some  forms  of  pyaemia,  they 
are  present,  and  may  cause  great  discomfort  to  the  patient.  It  is 


APHTHAE:    TREATMENT.  Jl 

difficult  to  explain  precisely  the  changes  which  initiate  the  formation  of 
aphthous  sores,  as,  for  example,  those  which  are  so  frequently  formed 
on  the  side  of  the  tongue,  just  where  the  organ  comes  in  contact  with 
some  tooth  which  is  undergoing  decay.  The  formation  of  a  little  pain- 
ful ulcer  is  the  result.  Such  ulcers  very  often  affect  the  mucous  mem- 
brane lining  the  lower  lip,  just  where  the  orifice  of  a  labial  gland  is 
situated.  Upon  examination,  we  find  upon  the  aphthous  spot  a  quantity 
of  soft,  moist  material,  which  consists  largely  of  epithelial  debris,  im- 
bedded in  and  everywhere  invaded  by  fungi,  especially  a  form  of  Oidium 
albicans,  in  various  stages  of  development! 

Now  it  has  been  supposed  that  the  fungi  are  the  cause  of  the  aphthae. 
The  spores  of  the  fungi,  it  is  said,  grow  and  multiply  on  the  surface  of 
the  mucous  membrane,  and  thereby  cause  inflammation  and  ulceration 
of  the  surface.  Secretion  takes  place  and  the  epithelium  becomes  soft 
and  spongy,  and  thus  the  growth  and  spread  of  the  fungus  is  favored. 
The  constituents  of  all  organic  secretions  at  the  temperature  of  the  body 
very  soon  undergo  decomposition,  and  the  germs  being  already  pre- 
sent, fungi  would  soon  develop,  and  would  grow  there  and  multiply. 
So  that,  instead  of  the  fungi  causing  the  disease,  it  is  more  probable  that 
morbid  actions  on  the  surface  of  the  mucous  membrane  give  rise  to 
changes  favoring  the  development  and  the  growth  of  the  vegetable 
organism,  and  that  in  these  prior  changes  the  true  origin  of  the  disease 
is  to  be  sought  for.  Fungi  and  their  spores  are,  as  I  have  said,  invari- 
ably present,  and  their  mere  presence  cannot  possibly  explain  the 
development  of  the  obstinate  little  ulcers  which  are  now  and  then  found 
in  persons  who  are  in  good  health,  though  they  trouble  such  only  for  a. 
very  short  time.  I  say  in  good  health,  but  have  little  doubt  that  I  use 
the  term  incorrectly,  and  though  I  cannot  tell  you  the  precise  particu- 
lars in  which  the  normal  condition  is  departed  from,  the  fact  of  the 
development  of  aphthae  is,  I  consider,  proof  that  the  person  affected  is 
not  in  perfect  health.  The  affection  is  not  purely  local,  and  it  is  most 
probable  that  the  occurrence  of  the  spots  in  the  mouth  is  preceded  by, 
and  intimately  connected  with,  an  altered  state  of  the  blood.  These 
little  aphthous  ulcers  are  sometimes  very  difficult  to  get  rid  of,  and  of 
course  a  great  number  of  infallible  remedies  have  been  discovered. 
Some  of  the  most  useful  applications  I  will  now  refer  to. 

Treatment  of  Aphthae. — Honey  and  borax,  the  Mel  Boracis  of  the 
Pharmacopoeia,  is  a  well-known  remedy  for  aphthae,  and  is  equally  effica- 
cious in  children,  adults,  and  old  people.  Chlorate  of  potash  also 
seems  to  exert  some  influence.  In  .the  case  of  adults  the  best  remedies 
are  those  which  are  known  to  chemically  change  the  fluids  upon  the 
surface  of  the  spots  which  favor  the  development  of  fungi,  and  upon 
which  they  live.  Tincture  of  Perchloride  of  Iron,  or  the  Liquor  Ferri 
Perchloridi  of  the  British  Pharmacopoeia,  is  a  very  potent  local  remedy. 


72  OFFENSIVE  BREATH. 

It  may  be  applied  to  the  surface  of  the  ulcer  with  a  camel-hair  brush. 
Dip  the  brush  into  the  Tincture  of  Perchloride  of  Iron,  and  just  touch 
the  surface  of  the  ulcer ;  leave  it  for  a  moment  or  two,  and  then  tell  the 
patient  to  wash  out  his  mouth  with  water.  But  it  is  better  to  mix  the 
iron  with  glycerine.  Equal  parts  of  pure  Glycerine  and  Tincture  or  Solu- 
tion of  Perchloride  of  Iron  make  a  very  valuable  application.  This  may 
be  applied,  as  I  have  recommended,  with  a  camel-hair  brush,  or  one 
teaspoonful  may  be  mixed  with  half  a  tumbler  of  water  or  more,  and 
the  mixture  used  frequently  (every  two  or  three  hours)  as  a  gargle  or  as 
a  wash  for  the  mouth.  The  patient  should  rinse  the  mouth  with  a  little 
tepid  water  afterwards,  for  the  frequent  application  of  iron  without  due 
care  causes  temporary  discoloration  of  the  teeth.  The  glycerine 
assists  the  adhesive  properties  of  the  solution,  and  the  morbid  changes 
taking  place  are  interfered  w-ith,  the  low  vegetable  organisms  destroyed, 
and  healthy  action  is  soon  reestablished. 

Another  very  useful  local  remedy  is  Nitrate  of  Silver.  The  stick  of 
fused  nitrate  of  silver  is  lightly  applied  to  the  spots,  or  a  strong  solution 
(ten  grains  to  an  ounce  of  distilled  water)  may  be  applied  with  a  brush 
every  day  until  the  cure  is  effected. 

The  Thrush  of  infants  usually  yields  to  increased  care  in  feeding. 
A  very  mild  laxative  is  sometimes  required,  and  oftentimes  a  little  lime- 
water  mixed  with  the  milk  is  of  great  use.  A  little  of  the  Mel  Boracis 
maybe  put  into  the  infant's  mouth  from  time  to  time.  My  friend,  the 
Professor  of  the  Diseases  of  Women  and  Children,  will  give  you  better 
advice  on  these  matters  than  I  can  do,  and  I  must  not  trench  further 
.upon  his  department. 

Offensive  Breath. — I  will  now  briefly  refer  to  a  derangement  which 
occurs  sometimes  in  connection  with  deranged  gland  action,  and  which 
gives  people  extreme  annoyance.  This  is  the  emission  of  a  very  offen- 
sive odorous  compound  in  the  breath.  It  comes  partly  from  the  glands 
connected  with  the  upper  part  of  the  respiratory  and  alimentary  mucous 
membrane  of  the  mouth  and  throat,  and  partly  probably  from  the  blood 
as  it  traverses  the  pulmonary  capillaries.  Even  the  individual  himself 
is  greatly  annoyed  by  the  smell  which  he  exhales. 

The  odor  is  not  by  any  means  the  same  in  all  cases,  though  I 
cannot  tell  whether  chemical  substances  of  different  kinds  are  really 
produced.  The  odorous  material  is,  I  believe,  however,  formed  in  a  great 
many  cases  by  the  glands  of  the  mucous  membrane  of  the  air  passages 
of  the  throat  and  of  the  mouth.  I  think  these  glands  secrete  the 
material  which  ought  to  be  removed  in  another  form  by  excretory  glands 
in  other  parts  of  the  body,  the  action  of  which  is  much  lessened  or 
stopped  iu  these  cases. 

As  offensive  breath  depends  upon  the  excretion  of  a  peculiar  organic 
matter  from  the  system,  in  order  to  effectually  get  rid  of  the  tendency 


METHODS  OF  TREATMENT.     ,.  73 

you  must  try  to  render  more  active  the  process  of  secretion  elsewhere. 
The  offensive  material  may  thus  be  got  rid  of  by  another  channel.  In 
fact  we  must  endeavor  to  get  it,  or  the  material  which  yields  it,  separated 
from  the  blood  by  other  glands,  particularly  those  which  discharge  their 
secretion  into  a  more  convenient  emunctory.  You  will  generally  find 
that  if  you  excite  the  action  of  the  ordinary  glands,  whose  office  it  is  to 
separate  odoriferous  compounds  from  the  blood,  and  discharge  them 
into  the  bowel,  the  disagreeable  smell  of  the  breath  will  soon  cease.  In 
short,  if  you  can  only  excite  the  liver,  the  largest  gland  in  the  body,  and 
the  solitary  and  other  excreting  glands  of  the  small  and  large  intestines 
to  a  little  increased  action,  and  keep  up  the  action  for  a  time,  the  patient 
will  cease  to  be  vexed  with  the  derangement.  Sometimes  he  is  afraid 
to  go  into  society,  or  be  much  in  the  company  of  other  people,  for  fear 
of  annoying  them,  as  much  as  he  is  himself  annoyed  by  the  smell  and 
taste  of  the  air  he  expires. 

Acting  upon  this  view,  the  first  remedies  to  be  tried  in  such  cases 
will  be  purgatives,  diuretics,  sudorifics.  In  all  cases  antiseptic  substances 
may  be  used  to  wash  out  the  mouth  frequently.  Charcoal  Pou,der  mixed 
with  water  as  a  wash  for  the  mouth.  A  teaspoonfu]  of  Tincture  of  Myrrh 
in  half  a  tumbler  of  water  is  also  a  good  wash.  Carbolic  Acid  is  useful 
in  such  cases.  A  weak  solution  of  carbolic  acid  (one  part  to  two 
hundred  of  water)  may  be  taken  internally,  and  the  mouth  may  be 
rinsed  out  frequently  with  a  stronger  solution.  Weak  carbolic  acid  spray 
may  also  be  tried  (see  p.  69).  Condy's  fluid  is  another  useful  remedy. 
The  mouth  may  be  washed  out  several  times  daily  with  a  solution  con- 
sisting of  half  a  teaspoonful  of  the  red  Condy  in  a  tumbler  of  water.  ' 

But  to  effect  any  lasting  relief,  you  must  be  particularly  careful  to 
regulate  the  patient's  diet.  Many  of  those  who  suffer  from  trouble  of 
this  kind  are  too  fond  of  rich  sapid  substances,  and  perhaps  take  too 
much  beer  or  porter,  and  upon  inquiry  you  will  find  perhaps  that  they 
habitually  eat  more  than  a  not  very  vigorous  stomach  can  properly  digest. 
The  excess  of  all  the  good  things  taken  is  imperfectly  oxidized,  and  the 
chemical  compounds  formed  clog  the  emunctories,  and  are  in  too  con- 
siderable proportion  to  be  got  rid  of  by  the  various  glands  whose  business 
it  is  to  remove  them  from  the  body.  Certain  materials  remain  in  the 
blood,  and  instead  of  being  discharged  from  the  bowels  are  eliminated 
in  a  crude  form  by  the  skin,  by  the  glands  of  the  mucous  membrane,  and 
in  part  by  the  lungs.  Thus  the  expired  air  becomes  contaminated.  It 
is  most  important  that  people  who  suffer  in  this  way  should  not 
overeat,  should  not  take  more  of  anything  than  is  required  for  nutrition, 
and  the  work  of  the  body.  As  a  matter  of  fact,  almost  every  one  does 
eat  more,  and  many  very  much  more,  than  is  required  to  keep  the  body 
in  health.  In  some  people,  perhaps,  in  consequence  of  the  liver  being 
less  active  than  it  should  be,  the  excess  of  food,  instead  of  being  excreted 
7 


74  OF  THE   USE   OF  PURGATIVES. 

in  an  altered  form  in  the  usual  way  by  the  solitary  and  other  glands  of 
the  bowels,  undergoes  exceptional  chemical  .change,  and  odoriferous 
compounds  are  formed  in  large  amount,  and  persistently,  to  the  patient's 
great  distress.  As  I  have  suggested,  the  way  to  remedy  this  great 
annoyance  is  to  encourage  the  more  free  action  of  the  glands,  whose 
ordinary  office  it  is  to  separate  this  class  of  substances  from  the  organism. 
Try  and  transfer  the  action  from  tne  surface  of  the  gastric  and  respiratory 
mucous  membrane  to  that  of  the  large  bowels. 

For  persons  who  have  long  suffered,  besides  giving  occasional  doses 
of  calomel,  blue  pill,  or  gray  powder,  you  must  prescribe  some  mild, 
harmless  purgative,  and  of  this  frequent  doses  may  be  taken.  You 
must,  in  fact,  take  care  that  the  bowels  act  freely,  and  that  the  excreting 
glands  do  their  work  efficiently. 

Almost  any  purgative  will  have  a  good  effect  in  many  cases : — 
Different  preparations  of  Colocynth,  Aloes,  Podophyllin,  Scammony,  Rhu- 
barb, Jalap,  Senna,  have  all  been  prescribed  with  benefit.  Several  other 
purgatives  have  been  recommended  by  different  authorities.  As  a 
general  rule,  it  is  better  not  to  give  large  doses,  as  it  is  necessary  not 
only  to  excite  the  action  of  the  intestinal  glands,  but  to  keep  it  up — to 
help  the  glands  from  day  to  day  to  do  their  work — to  give  them  just  a 
little  artificial  stimulus,  and  no  more.  From  three  to  five  grains  of  the 
Pilula  Colocynthidis  et  Hyoscyami,  or  the  same  amount  of  Pilula  Rhei 
Composita  may  be  ordered,  or  you  may  add  half  a  grain  or  less  of  the 
Extractum  Aloes  Barbadensis,  or  one  fifth  or  less  of  a  grain  of  Podo- 
phyllin  to  half  the  quantity  of  either  of  the  pills  mentioned.  At  first 
the  pill  should  be  taken  every  night,  or  just  before  dinner  ;  and  when  it 
begins  to  act,  every  other  day,  or  once  in  every  three  or  four  days.  Our 
object  is  to  so  regulate  the  bowels  as  to  cause  a  daily  action.  With 
some  persons  Scammony  acts  admirably.  One  or  two  grains  of  Resin  of 
Scammony,  Scammonitz  Resina,  may  be  added  to  two  or  three  of  the 
Compound  Colocynth  Pill,  which,  as  you  know,  contains  a  certain  pro- 
portion. A  patient  of  mine,  who  died  at  the  age  of  ninety-five,  had 
taken  Scammony  two  or  three  times  a  week,  for  many  years,  with  the 
greatest  benefit ;  but  neither  this  nor  Podophyllin,  nor  any' purgative  that 
I  know  of,  acts  equally  well  upon  all.  You  must  be  well  acquainted 
with  a  number  of  purgatives,  and  must  be  able  to  combine  them  in 
many  ways.  With  this  knowledge  you  will  often  be  able  to  hit  upon  the 
right  thing  for  particular  patients.  Our  predecessors  were  more  skilled 
in  prescribing  combinations  of  remedies  than  we  are.  There  is  not  the 
smallest  doubt  that  we  may  often  succeed  with  a  combination,  although 
we  may  quite  fail  to  effect  the  desired  object  with  a  single  drug. 

Use  of  Mercury. — Although  I  must  not  tire  you  with  mentioning  a 
multitude  of  remedies  for  a  condition  which  sometimes  resists  all  our 
efforts  to  relieve,  there  is  yet  one  thing  which,  as  already  stated,  is  of 


OF  THE   USE   OF  MERCURY.  75 

the  greatest  service,  if  given  with  judgment  and  due  care.  This  is 
mercury,  which,  as  you  know,  has  the  credit,  and  deservedly,  of  acting 
specially  on  the  liver,  but  which  also  causes  increased  action  of  most  of 
the  glands  connected  with  the  alimentary,  and  probably  also  the  absorbent 
system.  Mercury  is  one  of  the  remedies  upon  which  our  forefathers 
relied  more  implicitly  than  we  do.  I  think  they  often  gave  it  too 
frequently  and  in  unnecessarily  large  doses,  but  nowadays  I  think  we 
err  in  an  opposite  direction,  and  some  practitioners  not  only  do  not 
prescribe  mercury  in  cases  where  immediate  relief  would  follow  its 
administration,  but  refuse  to  prescribe  it  altogether,  and  encourage  the 
prejudice  needlessly  excited  in  the  minds  of  patients  against  its  use. 
Many  a  mother,  who  seems  to  be  shocked  at  the  very  name  of  calomel, 
nevertheless  frequently  gives  it  to  her  darlings  in  some  patent  powder 
which  she  has  used  for  years,  and  which  she  will  tell  you  is  a  most 
excellent  remedy  for  every  complaint  of  infancy  and  childhood. 

In  many  instances  in  which  the  patient  suffers  from  offensive  breath, 
with  a  dirty  tongue,  and  a  disagreeable  taste  in  the  mouth,  and  defective 
secretion  of  saliva,  with  perhaps  slight  nausea,  and  fulness  or  discomfort 
about  the  pit  of  the  stomach,  you  may  effect  a  cure  and  earn  the  grati- 
tude of  your  patient  by  prescribing  a  few  small  doses  of  blue  pill,  gray 
powder,  or  calomel.  The  medicine  should  be  given  with  a  little  rhubarb, 
compound  colocynth  pill,  or  some  other  purgative,  every  third  or  fourth 
night,  three  or  four  doses  in  all  being  ordered,  though  often  one  or  two 
only  will  be  required.  With  some  persons,  however,  no  compound  of 
mercury  will  agree,  and  in  these  very  exceptional  cases  you  must  employ 
other  purgatives,  and  give  various  salines  to  acton  the  bowels,  the  liver, 
and  kidneys,  especially  the  Nitrate  of  Potash,  Potasses  Nitras,  and  the 
Chloride  of  Ammonium,  Ammonii  Chloridum  ;  five  to  ten  grains  of  the 
first  and  twenty  grains  of  the  last,  dissolved  in  two  or  three  ounces  of 
water  on  rising  and  on  going  to  bed. 

Impaired  Appetite,  Loss  of  Appetite. — Next  let  me  say  a  few  words 
about  loss  of  appetite,  a  grievous  complaint  in  the  opinion  of  many 
people,  who  will  tell  you  with  dismay  and  astonishment  that  they  have 
ceased  to  enjoy  their  food.  They  never  feel  hungry,  and  never  eat 
with  appetite.  Sometimes  this  lack  of  inclination  for  food  is  due  to  the 
circumstance  that  the  complainants  ordinarily  eat  too  frequently,  and 
perhaps  also  eat  too  much.  There  is,  however,  unquestionably,  a  form 
of  loss  of  appetite,  or  impaired  appetite,  concerning  which  you  will  be 
consulted  from  time  to  time.  This  ailment  is  learnedly  known  as 
Anorexia,  the  scientific  term  for  loss  of  appetite,  the  word  being  derived 
from  the  Greek  a,  priv.,  op«|tj;  appetite. 

Loss  of  appetite  in  some  cases  is  rather  advantageous  and  conserva- 
tive. Many  a  man  who  boasts  of  always  enjoying  an  excellent  appetite 
would  be  more  fortunate  if  he  lost  it  from  time  to  time.  It  is  in  truth 


?6  LOSS   OF  APPETITE. 

a  misfortune  to  have  too  good  an  appetite  unless  you  have  great  self- 
command :  for  the  temptation  to  satisfy  it  is  considerable,  particularly  in 
the  case  of  those  who  are  well  off,  and  are  obliged,  owing  to  their  social 
position,  to  keep  good  cooks.  Many  such  persons  are  doomed  to  suffer, 
as  they  get  older,  from  having  eaten  too  much  at  an  earlier  period  of 
life.  He  who  wants  to  keep  himself  in  a  state  of  health  must  learn  to 
care  little  about  eating,  and  must  not  only  sit  down  to  his  meals  with 
an  appetite,  but  will  take  care  that  he  leaves  off  before  he  is  satisfied. 

Loss  of  appetite  very  frequently  depends  upon  a  state  of  the  mucous 
membrane  of  the  stomach  approaching  to  inflammation.  After  chronic 
inflammation  has  existed  for  a  considerable  time,  degeneration  of  the 
gastric  glands  and  other  tissues  takes  place,  and,  just  as  occurs  sometimes 
in  old  age  and  after  prolonged  exhausting  diseases,  digestion  becomes 
permanently  weak,  and  in  many  such  cases  there  is  loss  of  appetite. 
In  treating  many  of  these  cases,  it  is  necessary.to  help  digestion  artifi- 
cially, as  I  shall  explain  more  fully  in  another  lecture.  But  in  persons 
whose  stomach  is  fairly  healthy,  you  will  observe  that  anything  which 
induces  a  state  of  the  system  in  which  the  nerves  become  weak,  great 
fatigue,  over-much  brain  work,  anxiety,  mental  emotions,  fear,  or  joy 
may  give  rise  to  impaired  appetite. 

In  cases  in  which  the  loss  of  appetite  depends  merely  upon  some 
temporary  derangement  of  the  mucous  membrane  of  the  stomach,  many 
of  the  remedies  useful  in  weak  digestion  will  afford  relief.  See  p.  ioj. 
Very  often  a  change  of  diet  for  a  few  days  will  effect  a  cure.  Advise 
the  patient  to  take  nothing  but  milk  and  beef-tea,  with  a  little  stale 
bread,  or  corn  flour  or  lentil  flour  properly  cooked.  But  where  the  loss 
of  appetite  depends  upon' undue  wear  and  tear  of  the  nervous  system 
and  is  associated  with  mental  depression,  general  weakness,  inability  to 
exert  body  or  mind,  a  thorough  change  is  required — a  complete  altera- 
tion in  the  general  habits  of  life,  an  abandonment  for  a  time  of  the 
general  daily  routine  whatever  it  may  be.  Some  of  the  cases  in  which 
the  appetite  becomes  gradually  reduced,  or  completely  lost,  are  very 
curious  and  difficult  to  relieve.  They  occur  commonly  in  the  so-called 
hysterical  diatlicsis  (disposition,  constitution,  from  6ta  and  rio^ui,  I  place, 
I  dispose).  In  many  instances  there  certainly  is  no  structural  alteration 
either  in  the  stomach  or  in  any  part  of  the  nervous  system.  The  affec- 
tion is  no  doubt  due  to  some  deranged  nerve  action,  which  lasts  for  a 
time  and  then  passes  off  without  leaving  any  actual  lesion.  Hysterical 
(ya-tipa.,  the  uterus,  because  the  condition  is  often  associated  with  uterine 
derangement)  girls  and  women  are  very  apt  to  lose  their  appetite  for  a 
time.  At  first  having  little  desire  to  eat,  they  yield  to  the  impulse,  and 
gradually  bring  themselves  to  refuse  all  ordinary  food.  If  pampered 
and  pitied  and  regarded  as  interesting  objects,  they  become  worse  and 
soon  glory  in  refusing  to  eat.  Occasionally  we  do  meet  with  people  in 


FASTING   CELEBRITIES.  77 

a  state  almost  of  starvation  in  consequence  of  having  given  way  to  this 
feeling  of  want  of  appetite.  From  there  being  no  desire  for  food  there 
is  soon  acquired  an  actual  distaste,  dislike,  aversion.  People  often  tell  us 
that  the  mere  smell  of  food  at  once  causes  all  desire  for  it  to  disappear. 
There  may  be  danger  of  actual  starvation  if  the  patient  is  not  managed 
with  judgment ;  but  in  such  cases,  when  a  fatal  result  occurs,  death  more 
commonly  depends,  not  upon  actual  inanition,  but  upon  the  development 
of  some  intercurrent  malady  when  the  body  is  in  an  excessively  weak 
and  exhausted  state. 

Some  of  those  remarkable  "fasting"  celebrities  have  commenced  by 
degrees  as  above  suggested.  The  fasting  tendency  has  developed  itself 
after  loss  of  appetite,  occasioned  by  a  weak  state  of  the  digestive  pro- 
cess, due  to  imperfect  action  of  the  secreting  glands  of  the  mucous 
membrane  of  the  stomach,  or  of  the  nerves  which  excite  these  glands  to 
form  and  discharge  their  secretion,  and  which  has  existed  for  some  time. 
Fasting  becomes  a  passion.  The  patients  are  pitied  and  patronized  by 
the  people  about  them,  who  humor  them  in  every  conceivable  way,  and 
encourage  them  in  the  belief  that  they  are  peculiar  beings,  who,  unlike 
common  folk,  can  actually  live  without  eating.  This  gradually  leads  on 
to  deceiving.  They  systematically  refuse  anything  that  is  brought  to 
them,  and  are  soon  looked  upon  as  mysterious  persons.  Most  of  them 
surreptitiously  obtain  a  little,  and  in  this  way  may  live  in  a  weak, 
emaciated  state  for  a  great  length  of  time.  They  lose  weight  very 
slowly,  and  then  become  stationary,  which  fact  of  itself  is  proof  that 
nourishment  is  somehow  introduced  into  the  body.  An  excellent  account 
of  one  of  the  most  remarkable  of  these  cases,  together  with  much  matter 
of  importance  in  connection  with  the  general  subject  of  starvation,  has 
been  published  by  my  friend  Dr.  Robert  Fowler,  who  investigated  the 
evidence  in  the  most  thorough  manner.  I  strongly  recommend  all  who 
are  interested  in  the  physiological,  moral,  and  legal  aspects  of  fasting 
cases,  to  study  "A  Complete  History  of  the  Case  of  the  Welsh  Fasting 
Girl  (Sarah  Jacob),  with  Comments  thereon  ;  and  Observations  on 
Death  from  Starvation,"  by  Robert  Fowler,  M.D. 

Voracious  Appetite. — Occasionally  we  are  consulted  about  an  in- 
ordinate appetite.  The  patient  is  never  satisfied.  He  eats  a  pound  of 
beefsteak  or  more,  and  stills  feels  hungry.  In  some  persons  this  great 
desire  for  food  can  hardly  be  considered  as  a  disease  or  even  an  ailment. 
Children  are  occasionally  the  subjects  of  it.  No  doubt  the  state  is  often 
induced  by  injudicious  management. 

Remarkable  voracity  is,  however,  not  uncommonly  associated  with 

morbid  states.     In  certain  forms  of  mental  disease  it  is  a  prominent 

symptom,  and  in  Diabetes  (&a,  through,  and  /3cu'vu,  I  pass),  a  condition 

characterized  by  the  formation  and  elimination  of  an  enormous  quantity 

7* 


78  VORACIOUS  APPETITE. 

of  sugar  from  the  system,  the  appetite  is  very  frequently,  but  by  no 
means  constantly,  enormous.  Many  a  diabetic  can  consume  one  pound, 
or  even  two  pounds,  of  rump  steak  at  a  sitting,  and,  what  is  more 
remarkable,  thoroughly  digest  it.  Children  and  adults  who  suffer  from 
worms  have  often  a  very  large  appetite,  and  it  will  be  well  for  you  to 
bear  in  mind  this  circumstance.  Get  rid  of  the  worms  and  the  child 
again  eats  moderately. 

Inordinate  appetite  is-  spoken  of  as  Bulimia.  This  word,  like  many 
others  I  have  referred  to,  is  derived  from  the  Greek.  You  must  have 
been  struck  with  the  great  number  of  medical  terms,  and  particularly 
the  names  of  diseases,  which  are  Greek.  Those  among  you  who  have 
been  taught  Greek  at  school  enjoy  an  advantage  over  those  who  are 
ignorant  of  it,  inasmuch  as  the  meaning  of  a  vast  number  of  words  w*ill 
be  at  once  apparent.  It  is  somewhat  unfortunate  for  all  who  are  going 
into  the  profession  that  for  some  time  past  there  should  have  been  a 
dead  set  against  Greek,. for  no  one  can  learn  Medicine  without  at  the 
same  time  learning  the  meaning  of  a  number  of  Greek  words.  The 
word  Bulimia,  I  learn,  comes  from  /?c%,  an  ox,  or  /3o£>,  the  augmentative 
particle,  and  /U,«<fc,  hunger.  Bulimia,  or  voracious  appetite,  is  a  condition 
which  I  suppose  may  be  due  to  a  very  irritable  state  of  the  nerves  of 
the  stomach.  Not  unfrequently  the  affection  is  associated  with  vomiting, 
the  stomach  rejecting  its  contents  as  soon  as  they  have  accumulated 
up  to  a  certain  point. 

The  voracious  appetite,  as  we  see  it  existing  in  children  and  young 
people,  usually  comes  from  undue  encouragement.  The  greater  the 
desire  for  food  the  more  food  the  individual  eats,  and  so  he  goes  on 
until  he  succeeds  in  consuming  several  times  as  much  food  as  his  system 
requires.  Thus  is  thrown  upon  important  organs  the  task  of  elimi- 
nating a  quantity  of  useless  material  which  ought  not  to  have  been 
taken.  Sad  mistakes  are  frequently  made  by  parents  in  this  matter.  A 
child  perhaps  is  rather  thin,  and  therefore  encouraged  to  stuff,  and  by 
degrees  the  habit  of  taking  enormous  quantities  of  food  is  acquired,  with 
the  not  uncommon  result' to  the  patient  of  getting  thinner,  instead  of 
gaining  in  weight. 

Many  of  the  railway  navigators,  and  very  strong  laborers  who  have 
heavy  work  to  perform,  suffer  from  this  affection,  in  consequence  partly 
of  yielding  to  desires  which  their  high  wages  enable  them  to  gratify,  and 
partly  because  they  act  upon  the  generally  received  theory  propounded 
by  some  popular  philosophers,  that  the  more  you  consume  in  the  way  of 
food  the  more  work  will  your  machinery  perform — a  principle  which  may 
to  slight  extent  apply  to  machines,  but  is  altogether  inapplicable  to  any 
form  of  living  organism,  and  very  inaccurate  as  regards  the  work  per- 
formed by  man,  for  oftentimes  the  man  who  works  the  hardest  and  does 
the  most  is  he  who  eats  very  little.  The  railway  navigators  are  fine,  strong 


EVIL    OF  OVER-FEEDING.  79 

men,  many  from  5  feet  10  to  6  feet  high,  and  some  of  them  certainly  do 
consume  an  enormous  amount  of  animal  food,  probably  three  times  as 
much  as  is  required  for  the  performance  of.  their  work,  and  very  much 
more  than  would  be  a  most  liberal  allowance  for  them.  The  excess,  of 
course,  must  be  somehow  excreted,  and  before  it  can  be  excreted,  must 
be  acted  upon  by  the  secretions  of  various  organs,  especially  the  liver. 
This  and  many  other  glands  in  the  body  are  thus  called  upon  to  do  an 
excess  of  work,  and,  as  a  general  rule,  they  get  damaged  by  over  action, 
before  the  man  reaches  the  age  of  forty,  and  in  not  a  few  cases  the 
organs  completely  break  down  from  overstrain,  passing  into  various 
states  of  disease  which  soon  lead  to  death.  Indeed,  we  seldom  see 
one  of  these  men  as  old  as  forty.  The  great  majority  break  down 
before  that  age  is  attained.  The  model  navvy  has  unquestionably  to 
work  very  hard  indeed.  His  wages  depend  upon  the  amount  he  can 
lift,  and  the  rapidity  with  which  he  can  move  heavy  weights,  so  that  he  is 
encouraged  to  exert  himself  to  the  utmost.  The  more  work  he  can  do 
in  the  time,  the  more  money  he  earns.  Like  the  popular  philosopher, 
he  adopts  the  absurd  theory  that  the  more  he  eats  the  more  work  he  will 
be  able  to  do,  and  unfortunately  acts  upon  it,  squandering  his  money 
in  beef  and  beer  that  strain  his  organs  of  digestion,  assimilation,  and 
secretion,  and  ruin  his  health  and  shorten  his  life.  There  is  no  one  to 
teach  him  better,  so  he  acts  upon  unscientific  dogmas,  adopts  the  pre- 
judices of  his  order,  and  follows  his  own  inclinations. 

If  these  men  exercised  common  sense,  and  consumed  about  one- 
fourth  of  the  food  and  beer  many  of  them  indulge  in,  they  would  have 
a  chance  of  living  to  the  ordinary  period  of  life  ;  and  if  they  did  not  do 
quite  so  much  work  in  the  time,  they  would  work  for  many  years  longer. 
Many  men  who  belong  to  the  middle  and  upper  working  classes,  and 
who  have  lived  moderately,  are  often  very  strong  and  vigorous,  and 
able  to  endure  a  considerable  amount  of  bodily  fatigue  at  the  age  of 
sixty-five  or  seventy,  and  there  are  many  hard-workers  who  have  passed 
the  last  age. 

It  need  scarcely  be  said  that,  as  regards  the  treatment  of  these  cases 
of  inordinate  appetite,  it  is  a  matter  of  the  first  importance  to  carefully 
regulate  the  diet.  Small  doses  (three  to  five  minims)  of  Hydrocyanic 
or  Prussic  Acid,  Acidum  Hydrocyanicum  dilutum,  and  fifteen  or  twenty 
grains  of  Carbonate  of  Soda  in  an  ounce  of  water,  half  an  hour  before 
meals,  is  often  useful.  Liquor  Potassse,  Bismuth,  Tincture  of  Hop, 
Tincture  of  Henbane,  and  preparations  of  Opium  given  with  caution 
in  small  doses,  with  several  other  medicines,  maybe  prescribed  to  allay 
the  feeling  of  hunger  in  cases  in  which  it  depends  upon  unusual  irri- 
tability of  the  nerves  of  the  stomach. 

Nausea. — Some  persons  suffer  frequently  from  nausea,  and  a  most 
unpleasant  sensation  it  is  to  experience.  You  must,  however,  take  care 


8O  TREATMENT  OF  NAUSEA. 

to  distinguish  between  nausea  and  vomiting — actual  sickness.  People 
often  tell  you  they  are  often  sick,  although  they  never  reject  the  con- 
tents of  the  stomach.  This  feeling  of  nausea  is  a  very  common  one, 
and  is  met  with  in  various  degrees ;  sometimes  being  very  slight,  just  a 
little  qualmishness,  which  as  often  as  not  passes  off  soon  after  food  is 
taken  \  sometimes  so  severe  that  the  patient  feels  as  if  he  must  vomit. 
The  nausea,  perhaps,  comes  on  as  soon  as  he  wakes,  and  lasts  for  some 
hours,  and  possibly  may  not  entirely  disappear  for  many  days  at  a  time. 
Nausea  prevents  people  from  eating,  or  at  any  rate  makes  them  careless 
whether  they  eat  or  not,  and  entirely  takes  away  what  some  people 
highly  appreciate,  the  enjoyment  of  tasting,  masticating,  and  swal- 
lowing food.  There  are,  however,  persons  who,  instead  of  always 
having  a  good  appetite,  hardly  know  what  it  is  to  feel  hungry.  They 
eat  as  a  duty,  but  would  quite  as  soon  go  without  food.  The  feeling  of 
being  moderately  hungry, — looking  forward  to  and  desiring  food,  un- 
doubtedly is  a  pleasant  sensation,  especially  if  there  is  a  prospect  of  its 
being  gratified  within  a  reasonable  time. 

Nausea  may  be  brought  on  by  very  many  circumstances.  If  you 
were  to  take  but  a  i-4th,  or  even  the  i-6th,  of  a  grain  of  Tartar  Emetic, 
Antimonium  Tartaratum,  a  drug  much  in  vogue  fifty  years  ago,  but  now 
seldom  prescribed,  you  would  soon  learn  what  the  feeling  of  nausea 
is  like,  if  you  had  not  already  experienced  nausea  otherwise  caused. 
Those  who  go  a  short  journey  by  sea  often  suffer  from  nausea,  or  some- 
thing worse.  The  very  few  among  you  who  have  never  learned  to 
smoke  may  easily  study  the  phenomena  of  nausea,  and  will  afterwards 
remember  what  is  meant  by  the  term  if  you  smoke  a  portion  of  a  cigar 
for  the  first  time.  If  the  feeling  should  be  so  unpleasant  as  to  make 
you  determine  not  to  repeat  the  experiment,  perhaps,  upon  the  whole, 
it  will  be  so  much  the  better,  for  smoking  wastes  a  great  deal  of  time 
which  might  be  better  employed. 

Slight  nausea  is  no  doubt  dependent  in  the  ordinary  way  upon  a 
somewhat  disturbed  state  of  the  mucous  membrane  of  the  stomach  or  a 
deranged  condition  of  the  liver,  or  upon  both.  The  sensation  may  be 
relieved  in  many  ways.  Pepper  and  various  pungent  substances,  which 
excite  the  secretion  of  the  stomach,  are  often  useful.  Cayenne  pepper 
and  Curry  powder  are  well  known  remedies.  But  nausea  seems  to  be 
due  in  many  cases  to  some  slightly  impeded  circulation  in  the  vessels 
of  the  mucous  membrane  of  the  stomach,  and  those  of  the  liver.  The 
latter  gland  is  sometimes  much  enlarged  in  consequence  of  the  large 
quantity  of  blood  which  accumulates  in  it.  After  a  few  days,  especially 
if  the  patient  rests,  it  regains  its  usual  volume  without  having  undergone 
any  permanent  alteration,  and  without  being  in  any  way  damaged. 
Nausea,  dependent  upon  temporary  vascular  congestion,  may  be  re- 
moved by  promoting  a  more  free  flow  of  blood  through  the  vessels  of 


•   EVIL   EFFECTS   OF  ALCOHOL.  8 1 

these  organs.  A  warm  bath,  or  a  Turkish  bath,  will  very  often  effect  a 
cure,  particularly  in  the  case  of  those  whose  habits  are  too  sedentary. 
Plenty  of  fresh  air,  and  but  little  food  for  a  day  or  two,  will  sometimes 
alone  cause  the  discomfort  to  cease.  If  these  means  fail,  a  mercurial 
purgative  should  be  tried.  See  p.  75. 

Many  healthy  persons  who  suffer  from  time  to  time  from  nausea 
depending  upon  over-sensitiveness  of  the  stomach,  liver,  and  other 
glands,  discover  not  only  how  to  cure  themselves  in  a  very  simple  way, 
but  also  how  to  keep  themselves  well.  They  find  it  necessary  from 
time  to  time  to  give  their  stomachs  rest  for  from  twelve  to  twenty-four 
hours,  and  then  they  get  well.  The  prejudice  that  exists  against  going 
without  one's  dinner  now  and  then  is  really  most  absurd.  An  occasional 
fast  is  almost  necessary  for  many  who  live  even  moderately  well,  and 
some,  especially  ladies  who  are  little  out  of  doors,  and  take  little 
exercise,  would  be  in  much  better  health,  and  would  feel  in  better 
spirits,  stronger  and  more  capable  of  moving  about  if  they  w6uld  not 
dine  quite  every  day,  as  well  as  take  a  good  lunch.  It  is  also  ad- 
vantageous to  take  fish  and  no  meat  twice  a  week.  People  who  suffer 
from  nausea  or  biliousness  and  want  of  appetite, — and  there  are  not  a 
few  who  are  habitually  ailing  in  this  way,  who  seldom  indeed  during  a 
long  life  have  felt  really  well, — often  find  out  for  themselves,  or  they 
are  told  by  too  officious  friends,  that  a  little  alcohol  just  before  a  meal 
will  give  relief.  Brandy,  gin,  bitters  of  various  forms,  pick-me-ups,  etc. , 
are  taken  for  this  purpose,  and  a  worse  system  has  never  been  carried 
out.  That  bad  habit  of  taking  now  and  -then  ginger  brandy,  cherry 
brandy,  or  the  worse  one  of  frequently  imbibing  strong  sherry  for 
relieving  nausea,  a  sensation  of  hollowness,  or  faintness,  or  fulness,  or 
all-overishness,  or  what  not,  has  been  the  ruin  of  thousands.  Having 
once  acquired  it,  many  find  it  far  more  difficult  to  give  up  this  vicious 
practice  than  would  be  supposed. 

Bad  indeed  is  the  fashion  of  taking  just  before  dinner  a  small  dose 
of  brandy,  or  ginger  brandy,  or  dry  sherry,  or  some  other  strong 
alcoholic  stimulant,  just  to  excite  the  appetite  in  order  that  justice  may 
be  done  to  the  repast — that  is,  that  people  may  swallow  more  than  is 
good  for  them,  and  more  than  they  can  easily  digest.  If  a  man  cannot 
eat  his  dinner  without  first  taking  a  stimulant,  he  had  better  go  without 
it.  He  might  wait  a  few  hours,  and  then  he  would  probably  be  able  to 
take  simple  food  without  the  help  of  condiments  or  stimulants.  The 
habit  of  taking  alcohol  too  frequently  and  too  regularly  often  comes 
from  this  most  objectionable  practice  of  taking  a  little  stimulant  before 
dinner.  The  unfortunate  person  who  is  regarded  as  the  "  life  of  the 
party"  cannot  help  himself,  for  he  must  be  sprightly  and  entertaining 
from  the  beginning  to  the  end  of  the  feast. 

Doctors  are  often  accused  of  teaching  and  encouraging  people  to 

F 


82  ACQUIRING  INTEMPERATE  HABITS. 

"tipple,"  because  in  certain  morbid  conditions  they  have  found  it 
necessary  to  prescribe  stimulating  doses  of  alcohol.  For  one  person, 
however,  recommended  to  take  alcohol  by  us,  how  many  thousands  who 
have  never  consulted  a  doctor  in  their  lives,  take  it  on  other  grounds, — 
take  it  because  they  like  it,  or  because  they  see  others  take  it,  or 
because  .they  like  the  sensation  it  produces  ?  Many  will  admit  that  they 
began  when  they  suffered  from  a  "sinking  sensation,"  or  from  nausea, 
or  uneasiness  about  the  stomach,  and  after  having  been  troubled  from 
time  to  time,  discovered  that  the  unpleasant  feeling  was  invariably 
relieved  if  they  swallowed  a  little  brandy.  The  little  brandy  gradually 
increases  in  amount.  Nausea  and  other  unpleasant  sensations  instead 
of  occurring  once  or  twice  in  the  day,  occurred  a  great  many  times,  and 
the  victim  will  tell  you  that  he  was,  after  a  time,  obliged  to  resort  to  the 
remedy  in  order  to  do  his  work.  Of  those  who  allow  themselves  to  act 
thus  not  a  few  become  slaves  to  alcohol,  and  then  a  more  deplorable 
phase  is  soon  reached.  They  are  no  longer  able  to  abstain,  all  self- 
command  is  lost,  and  the  unfortunate  people  are  no  longer  able  to 
control  themselves  in  any  way,  while  few  will  submit  to  be  influenced 
and  controlled  by  others.  This  state  may  last  for  a  time,  and  then  a 
new  and  very  remarkable  phenomenon  is  occasionally  developed.  The 
intemperate  individual  abstains  entirely,  and  hates  alcohol  even  more 
than  he  loved  it  before.  He  despises  himself,  is  overwhelmed  with 
remorse.  In  a  little  time  he  gives  up  the  role  of  sinner  and  adopts  that 
of  saint,  and  saint  of  the  most  despotic  and  uncompromising  kind. 
For  a  long  time  he  was  quite  unable  to  govern  himself,  but  now  he  is 
determined  to  govern  others,  and  in  a  very  decided  manner.  He  ex- 
presses virtuous  indignation  against  all  \vho  take  or  sell  or  produce 
alcohol,  and  thinks  it  very  hard  that  he  is  not  abje  to  punish  every  one 
who  prefers  wine  to  water,  and  who  dares  even  to  look  at  a  stimulant. 
We  have  the  curious  spectacle  of  a  very  small  minority  who,  by  their 
own  confession,  for  some  lime  could  not  keep  themselves  within  the 
bounds  of  reason,  now  seeking  to  impose  their  arbitrary  veto  Upon  the 
very  large  majority  who  have  never  had  the  slightest  difficulty  in  either 
taking  a  little,  much,  or  abstaining  altogether,  as  seemed  to  be  the  best 
for  their  organisms  at  the  time.  With  as  much  reason  might  power  be 
given  to  convalescent  lunatics  to  put  all  the  sane  people  in  straight 
waistcoats,  or  shut  them  up  in  padded  rooms. 

The  unfortunate  people  who  cannot  taste  a  certain  fluid  without 
making  themselves  worse  than  animals,  will  sometimes  come  to  you  and 
crave  advice.  You  may  be  of  some  use  to  them  by  ordering  certain 
medicines  which  will  act,  to  some  extent,  like  alcohol,  but  which  are 
not  open  to  the  objections  pertaining  to  that  substance.  Ammonia  is 
often  of  use.  You  may  order  a  teaspoonful  of  Salvolatile,  Spiritus 
Ammonite  Aromaticus,  with  twice  as  much  Compound  Tincture  of 


THIRST.  83 

Cardamoms,  Tinctura  Cardamomi  Composita,  in  a  wineglassful  of 
water  every  three  or  four  hours,  for  a  few  days  or  a  week.  Tincture  of 
Hop,  Tinctura  Lupuli,  Tincture  of  Orange,  Tinctura  Aurantii,  or  Syrup 
of  Orange,  Syrupus  Aurantii,  are  good  additions  to  improve  the  flavor 
of  the  dose. 

As  regards  medicines  for  the  relief  of  nausea,  you  will  find  that  from 
one  to  three  or  four  drops  of  Hydrocyanic  acid,  Acidum  Hydrocyanictim 
dilutum,  in  two  tablespoonfuls  of  water,  or  with  a  little  Bicarbonate  of 
Soda  or  Potash,  or  in  half  a  tumbler  of  Soda  or  Potash  water  before 
food,  will  be  useful.  In  some  cases  three  or  four  drops  of  Solution  of 
Ammonia,  Liquor  Ammonia,  in  a  wineglassful  of  water,  when  the  feel- 
ing of  nausea  is  mp,st  troublesome,  may  cure  the  ailment.  A  small  dose 
of  blue  pill  or  calomel  will  sometimes  cure  very  obstinate  nausea, 
although  many  other  remedies  may  have  failed.  In  not  a  few  instances 
counter-irritation  is  also  of  use.  A  mustard  poultice  may  be  applied 
over  the  region  of  the  stomach  and  liver  for  twenty  minutes  every  third 
or  fourth  day.  Or  a  wet  rag,  covered  with  oiled  silk,  or  a  piece  of 
Spongio-piline,  wetted  with  warm  water,  and  worn  for  an  hour  or  two, 
will  frequently  be  found  efficacious.  See  also  the  treatment  of  Indiges- 
tion, p.  97. 

Thirst. — It  is  probable  that  thirst  is  less  dependent  on  the  state  of 
the  stomach  than  is  the  feeling  of  hunger,  though  it  is  quite  true  that 
thirst  may  be  excited  by  Cayenne  pepper,  and  irritating  matters  intro- 
duced into  the  stomach.  It  often  occurs  in  connection  with  certain 
forms  of  indigestion,  and  is  almost  always  experienced  an  hour  or  two 
after  a  good  meal,  during  which  little  fluid  has  been  taken.  The  fact 
that  thirst  is  relieved  by  injecting  fluid  into  the  blood,  and  by  the 
absorption  of  fluid  from  the  genejal  surface, — that  it  is  present  in  all 
febrile  states,  and  comes  on  after  diarrhoea,  after  the  action  of  ordinary 
purgatives,  and  after  free  perspiration,  however  excited, — would  seem  to 
indicate  that  the  feeling  is  somehow  due  to  the  reduction  of  water  in  the 
blood.  The  sensation  of  thirst  seems  to  be  experienced  principally 
in  the  back  of  the  mouth  and  fauces.  Considering  this  part  of  the 
mucous  membrane  very  readily  gets  dry  even  in  health,  it  is  probable 
that  very  fine  nerve-fibres,  close  to  the  capillary  network  of  wide 
capillaries  having  an  unusual  number  of  bioplasts  in  their  walls,  are 
afferent  fibres,  and  take  part  in  the  initiation  of  the  phenomena  which 
constitute  what  we  know  as  thirst.  The  capillaries  and  nerve-fibres 
referred  to  in  that  part  of  the  mucous  membrane  which  covers  the 
convex  surface  of  the  epiglottis,  and  which  is  admirably  situated  for 
the  detection  and  registration  of  varying  degrees  of  moisture  of  the 
mucous  membrane,  are  represented  in  pi.  XCIII.  of  "  How  to  Work 
with  the  Microscope,"  5th  edition. 

No  rigid  rules  can  be  laid  down  as  to  the  exact  quantity  of  fluid 


84  INDIGESTION:  DYSPEPSIA. 

that  sh'ould  be  taken  per  diem,  for  the  proper  amount  vaiies  in  indi- 
vidual cases.  It  should  undoubtedly  bear  a  certain  relation  to  the 
solids  taken,  but  in  practice  it  is  impossible  to  say  precisely  what  this 
relation  should  be.  One  man  finds  he  digests  better,  and  feels  better,  if 
he  takes  from  two  to  three  pints  of  fluid  daily.  Another  taking  about 
the  same  amount  of  solid  food  or  more,  finds  that  half  as  much  fluid 
suits  him  best.  When  in  practice,  you  will  find  that  some  people  are 
habitually  taking  too  much  to  drink,  and  some  too  little.  You  will  meet 
with  cases  of  greatly  impaired  digestion,  general  weakness,  and  feeble 
health,  evidently  due  to  the  habitual  introduction  of  too'  much  liquid 
with  the  food,  the  patients  nevertheless  always  feeling  thirsty.  On  the 
other  hand,  not  a  few  persons  complaining  of  muscular  and  nerve  pains 
in  various  parts  of  the  body,  who  are  evidently  suffering  from  a  tendency 
to  gouty  and  rheumatic  affections,  maybe  completely  cured  by  a  course 
of  water-drinking,  three  or  four  pints  or  more  of  water  being  taken 
during  the  twenty-four  hours.  By  ordering  this  plan  to  be  continued 
for  two  or  three  weeks  at  a  time,  three  or  four  times  in  the  year,  we  may 
succeed  in  washing  out  the  tissues  thoroughly,  and  keeping  them  in  a 
healthy  condition. 

INDIGESTION:    ITS   NATURE   AND   TREATMENT. 

Indigestion — Dyspepsia. — Many  lectures  might  be  devoted  to  the 
consideration  of  dyspepsia,  but  I  shall  only  attempt  here  to  give  you  an 
imperfect  outline  of  the  subject,  with  a  few  suggestions  concerning 
points  of  treatment  which  seem  to  me  of  some  importance.  The  pro- 
cess of  digestion,  when  it -occurs  naturally,  goes  on  without  the  slightest 
disturbance,  and  without  our  being  aware  of  what  is  taking  place. 
Those  of  you  who  are  in  perfect  health  probably  do  not  know,  from  any 
feelings  you  experience,  that  you  possess  such  an  organ  as  a  stomach, 
with  five  and  twenty  feet  or  more  of  small  intestine  beyond  it.  Many 
come  to  study  medicine  without  knowing  what  a  stomach  is  like,  until 
they  see  one  in  the  dissecting-room,  so  little  can  we  learn  concerning  the 
structure  and  action  of  our  own  organs  from  sensations  experienced,  or 
from  the  contemplation  of  what  is  going  on  in  our  bodies.  But  there  are 
some  unfortunate  persons  who,  without  being  actually  ill,  hardly  swallow 
anything  without  soon  afterwards  being  made  painfully  conscious  of  the 
existence  of  their  stomach,  and  its  exact  whereabouts.  They  cannot 
define  its  precise  limits,  but  they  very  frequently  suffer  from  uneasiness, 
or  actual  pain,  which  is  referred  to  the  neighborhood  of  the  stomach, 
and  seems  to  be  situated  in  structures  some  distance  beneath  the  surface 
of  the  skin.  This  discomfort  usually  comes  on  after  taking  food,  but  in 
certain  forms  of  indigestion  the  pain  precedes  the  introduction  of  solids 
or  fluids,  and  when  this  is  the  case  it  may  be  relieved  by  food.  When 
pain' or  uneasiness  comes  on  some  time  after  food  has  been  takea  it 


DIFFICULT  DIGESTION.  85 

may  continue  as  long  as  the  process  of  digestion  lasts,  but  then  the  pain 
subsides,  and  does  not  usually  return  until  after  the  next  meal  has  been 
taken.  Indigestion  is  learnedly  spoken  of  as  dyspepsia,  which  comes 
from  two  Greek  words,  6vg,  with  difficulty,  and  7r£7rrm>,  to  concoct  or 
digest. 

The  pain  or  discomfort  consequent  upon  slow  or  imperfect  digestion, 
or  indigestion,  may  be  induced  by  many  different  circumstances.  There 
may  be  some  deranged  action  of  the  mucous  membrane  of  the  stomach, 
and  hyper-sensitiveness  (jWp,  over,  or  above)  ;  or  severe  pain  may  be 
occasioned  by  an  altered  state  of  the  circulation,  caused  directly  or  in- 
directly (by  reflected  action)  influencing  the  nerves  of  the  stomach. 
Very  many  times  one  comes  across  cases  of  what  may  be  called  ordinary 
indigestion,  where  there  is  no  actual  disease,  but  still  where  a  trouble- 
some and  almost  constant  fixed  pain,  aching,  heaviness,  or  sense  of 
weight,  or  fulness,  or  of  pressure  is  complained  of,  so  wearying  to  the 
patient  that  it  deters  him  from  taking  food.  In  consequence  he  gets 
thin  and  pale,  and  perhaps  loses  heart  and  becomes  weak  and  de- 
spondent, and  is  much  out  of  health. 

If  we  could  see  the  mucous  membrane  in  many  cases  of  indigestion, 
we  should  no  doubt  find  it  unduly  vascular.  There  would  be  a  state 
approaching  to  inflammation  over  a  limited  area  only,  possibly  over  a 
portion  of  mucous  membrane  not  larger  than  a  sixpence.  Here  the 
vessels  would  be  seen  distended,  the  blood  moving  very  slowly  along 
the  capillary  tubes,  and  some  exudation  from  the  vessels  would  very 
likely  be  found  in  the  surrounding  tissue.  The  nerves  distributed  to 
the  mucous  membrane  would  have  undergone  those  changes  which 
result  in  their  being  unduly  excitable.  Their  bioplasts  and  those  of  all 
the  tissues  in  the  neighborhood  would  be  found  enlarged.  Partly  from 
this  last  circumstance,  and  partly  from  the  pressure  upon  them  exerted 
by  the  undue  distention  of  the  vessels,  the  sensitive  nerve-fibres  would 
transmit  impressions  of  a  painful  character.  The  state  of  the  mucous 
membrane  I  have  just  referred  to  may  soon  give  place  to  the  normal 
condition,  or  it  may  persist  and  lead  on  to  a  state  of  things  which  may 
result  in  the  formation  of  an  ulcer,  the  nature  and  symptoms  of  which 
disease  I  shall  have  to  refer  to  in  another  part  of  my  course. 

Of  Pain,  and  of  the  Arrangement  of  the  Finest  Nerve-fibres  in  the 
Stomach  and  Intestines. — The  whole  question  of  pain  is  one  of  great 
interest  and  importance,  and  as  the  pain  in  indigestion  and  other 
derangements  of  the  digestive  organs  is  experienced  through  the  in- 
strumentality of  nerves  which  in  the  normal  state  transmit  impressions 
only  of  which  we  are  not  cognizant,  it  will  be  worth  while  to  consider 
the  arrangement  of  the  nerve-fibres  concerned,  and  discuss  their  prob- 
able action.  Nor  can  disorders  of  the  intestinal  canal  be  understood 
without  the  knowledge  of  the  way  in  which  healthy  action  is  governed 
8 


86  NERVES   OF   THE  INTESTINE. 

and  carried  out.  Although  the  bowels  in  every  part  are  very  freely 
supplied  with  nerve-fibres,  so  long  as  the  functions  are  properly  dis- 
charged  we  remain  quite  unconscious  of  the  existence  of  any  exquisitely 
sensitive  tissues  in  connection  with  the  alimentary  canal.  Fortunate  are 
all  who  pass  through  life  without  discovering  that  sensitive  nerves  are 
distributed  to  the  intestines.  We  know  nothing  of  the  changes  taking 
place  in  the  stomach  and  bowels  until  something  interferes  with  their 
due  performance.  Then  indeed  we  become  aware  of  the  contrast 
between  ease  and  certain  forms  of  drs-ease  as  it  affects  these  wonderful 
structures. 

The  whole  of  the  intestinal  tissues  are  most  abundantly  supplied  with 
nerves.  You  will  find  in  some  of  the  older  anatomical  books,  descrip- 
tions given  which  would  give  you  a  very  imperfect  notion  either  of  the 
number  or  arrangement  of  the  nerve-fibres.  In  fact,  the  most  important 
and  most  extensive  portion  of  these  nerve-fibres  is  known  to  few  anat- 
omists even  now,  and  only  a  few  years  ago  it  would  have  been  impos- 
sible for  us  to  form  a  conception  of  the  true  arrangement  of  the  nerve- 
fibres  of  the  digestive  tract,  or  of  the  actual  phenomena  going  on  during 
life  in  any  part  of  it.  All  the  tissues  entering  into  the  formation  of  every 
part  of  the  intestinal  canal  are  most  abundantly  supplied  with  very  fine 
nerve-fibres,  although  you  might  read  much  that  would  lead  you  to  infer 
that  the  mucous  membrane  and  muscular  coat  of  the  stomach  and  in- 
testines received  very  few.  nerves.  It  used  to  be  supposed  that  the  con- 
traction of  involuntary  muscular  tissue  resulted  from  direct  irritation  or 
stimulation.  And  even  now  little  attention  is  given  to  the  highly  im- 
portant part  played  by  the  nerves  and  nerve-centres  which  influence 
every  action  and  every  movement  connected  with  every  part  of  the 
digestive  process.  In  every  part  of  the  digestive  apparatus,  from  the 
mouth  to  the  anus,  the  secreting  and  absorbing  as  well  as  the  muscular 
apparatus  receives  an  abundant  supply  of  nerve-fibres. 

The  muscular  fibres  which  are  distributed  around  the  stomach  and 
intestine,  as  well  as  those  situated  just  beneath  the  mucous  membrane, 
are  frequently,  though  not  constantly,  in  active  movement,  each  fibre 
alternately  shortening  and  lengthening — undergoing  contraction  and 
relaxation, — actions  which  occur  at  different  times  in  different  parts-of 
the  alimentary  canal,  and  in  all  alternate  probably,  with  comparatively 
long  periods  of  rest  or  quiescence.  But  invariably  the  contraction  of 
the  muscular  tissue,  like  that  of  every  form  of  voluntary  and  involuntary 
muscle,  takes  place  under  the  influence  of  the  nerves. 

Besides  the  nerves  distributed  in  networks  and  plexuses  to  the 
mucous  membrane  and  muscles  in  great  number,  there  is  a  highly  com- 
plex system  of  ganglia  or  nerve-centres  little  appreciated,  and  indeed 
hardly  known  to  more  than  a  few  observers.  You  all  know,  of  course, 
what  multitudes  of  ganglia  help  to  constitute  the  sympathetic  system 


NERVE-GANGLIA  AND  PLEXUSES.  8/ 

Many  of  the  large  ones  you  see  in  the  course  of  your  work  in  vhe  dis- 
secting-room, and  the  more  skilfully  you  dissect,  the  more  ganglia  will 
you  find.  You  are  also  well  aware  of  the  complex  interlacement  of 
coarse  nerve-fibres  and  trunks  in  many  parts  of  the  abdominal  sympa- 
thetic system,  but  from  the  most  perfect  ordinary  dissection  that  can 
be  made,  you  will  form  but  a  very  imperfect  idea  of  the  vast  number 
of  minute  ganglia  and  ganglion  cells  connected  with  what  seem  to  be 
excessively  fine  nerve  threads. 

•  If,  now,  from  a  piece  of  small  intestine  pinned  out  upon  a  strip  of 
wood  or  cork,  you  will  detach  carefully  the  mucous  membrane  from  the 
muscular  coat,  and  soak  it  for  a  few  days  in  equal  parts  of  glycerine  and 
water,  replacing  the  solution  from  time  to  time  with  fresh  fluid,  and 
then  gradually  add  stronger  glycerine,  you  will  find  the  tissue  will  assume 
a  state  favorable  for  the  demonstration  of  the  ganglia.  Small  pieces  of 
the  submucous  tissue  are  to  be  snipped  off,  placed  on  a  glass  slide,  and 
after  being  gently  teased  out  with  pins  or  needle  points,  and  moistened 
with  fresh  glycerine,  covered  with  thin  glass.  If  you  examine  such 
a  specimen  under  an  inch  object-glass,  you  will  have  no  difficulty  in 
demonstrating  a  vast  network  of  ganglia  and  nerve-fibres.  You  will 
observe  hundreds  of  little  microscopic  ganglia  on  different  planes,  and 
these  you  will  discover  are  all  connected  with  one  another  by  numerous 
intercommunicating  bundles  of  nerve-fibres,  constituting  quite  a  net- 
work or  plexus  of  fibres  and  ganglia.  The  ganglia  in  question  were 
discovered  some  years  ago  by  Meissner;  Auerbach  had  some  years  pre- 
viously described  plexuses  and  ganglia  close  to  the  muscular  coat.  But 
of  course  these  observations  were  contradicted  by  some  and  ignored  by 
others,  and  long  papers  were  written  by  great  authorities  to  prove  that 
the  nerves,  ganglia,  and  plexuses  were  really  vessels,  the  points  of  diver- 
gence of  which,  in  their  opinion,  had  been  mistaken  for  ganglia.  There 
is,  however,  no  difficulty  in  demonstrating  these  ganglia  most  conclu- 
sively. I  have  many  times  shown  in  connection  with  the  course  of 
physiological  anatomy  which  I  used  to  give  in  this  college,  the  cells 
composing  them,  with  the  bioplasm  of  the  nerve-cells  and  fibres  arti- 
ficially stained  with  carmine,  and  I  can  assure  you,  with  the  greatest 
confidence,  that  the  cells  are  true  nerve-cells,  and  that  fine  nerve-fibres 
pass  from  them  to  supply  with  nerve-fibres  the  tissues  of  the  mucous 
membrane,  as  well  as  the  thick  layers  of  muscular  tissue  which  encircle 
the  intestinal  canal.  So  numerous  are  the  fine  nerve-fibres  that  there  is 
not  a  portion  of  tissue  the  one  five-hundredth  of  an  inch  in  width  which, 
does  not  receive  an  abundant  supply. 

Every  villas  of  the  intestinal  canal  is  supplied  with  nerve-fibres,  and 
the  action  of  each  of  its  several  component  tissues  is  presided  over  by 
nerve-cells.  Every  gastric  gland  as  well  as  every  intestinal  follicle  is 
also  abundantly  supplied.  Its  structural  connection  with  the  nerve- 


88  PAIN-CONDUCTING   NERVE-FIBRES. 

fibres  is  a  nerve-centre,  or  rather  a  group  of  ganglia  by  which  nerve 
action  is  regulated,  the  changes  resulting  in  the  secretion  of  gastric  juice 
and  intestinal  fluid  governed,  and  actions  emanating  from  other  nerve- 
centres  or  groups  harmonized.  The  nerves  have  also  much  to  do  with 
the  simultaneous  discharge  of  the  secretion  upon  the  surface  of  the 
mucous  membrane  from  thousands  of  microscopic  glands. 

But  in  spite  of  this  marvellous  nerve  supply,  as  long  as  things  go  on 
rightly,  you  are  not  cognizant  of  any  of  the  changes  which  are  taking 
place.  The  intestinal  tube  is  sometimes  full  and  distended,  sometimes 
relaxed,  sometimes  contracted,  and  yet  all  these  alterations  in  volume, 
all  this  stretching  and  contraction,  take  place  for  the  most  part  without 
our  knowing  anything  about  it.  If,  however,  these  same  phenomena 
occur  in  an  exaggerated  way,  or  if  anything  interferes  with  their  due 
performance,  we  very  soon  become  conscious  that  things  are  not  as 
they  should  be.  We  cannot  always  say  exactly  what  part  of  the  intes- 
tine is  in  fault,  or  what  sets  of  ganglia  are  disturbed  in  their  action,  but 
we  experience  discomfort  if  not  actual  pain,  and  almost  instinctively 
we  so  act  as  to  give  the  whole  digestive  system  little  to  do.  We  let  it 
rest  for  a  time.  We  take  no  food  or  confine  ourselves  to  small  quan- 
tities of  easily  digested  slops,  and  in  the  course  of  a  short  time  things 
generally  right  themselves. 

But  surely  it  is  very  remarkable,  seeing  how  unconscious  we  are  in 
the  healthy  state,  at  least  as  far  as  feeling  is  concerned,  of  the  existence 
of  the  intestinal  canal,  that  when  its  action  is  much  deranged,  the  pain 
experienced  should  be  so  very  severe,  and  so  difficult  to  bear,  as  is  the 
particular  pain  which  is  developed  at  the  peripheral  distribution  of  the 
sympathetic  nerve-fibres,  the  ordinary  actions  of  which  go  on  quietly 
and  almost  incessantly,  but  quite  unconsciously. 

The  peritoneum  ("£/-><',  around,  and  reu'w,  to  extend)  or  thin  membrane 
external  to  the  muscular  coat  of  the  intestine,  which  is  supplied  with 
nerves  from  these  same  ganglia,  and  which  in  the  healthy  state  is  always 
sliding  smoothly  in  contact  with  the  moistened  surface  of  another  layer 
of  the  same  delicate  tissue,  becomes  exquisitely  sensitive  in  inflammation. 
The  pain  of  peritonitis  (^cpi,  around,  r«Vw,  to  extend,  and  *-?f,  rash,  the 
suffix  itis  denoting  inflammation)  is  one  of  the  most  terrible  forms  of 
pain  that  any  human  being  can  have  to  bear,  and  yet  these  same  nerve- 
fibres  which  are  concerned  in  the  causation  of  most  horrible  suffering, 
act  as  a  general  rule  quite  unconsciously,  do  their  work  without  our 
knowing  anything  of  them,  or  of  the  action  of  the  apparatus  they  govern. 

Pain-conducting  Nerve-fiLres. — The  nerve-fibres  concerned  in  the 
transmission  of  the  sensation  we  call  pain,  are  not,  I  think,  those  which 
have  been  regarded  as  special  sensitive  nerves,  but  the  fine  fibres  which 
were  first  demonstrated  by  me  close  to  the  capillary  vessels,  and  so  sit- 
uated that  any  change  in  vascular  turgescence  would  affect  them.  As 


GASTRODYNIA.  89 

is  well  known,  the  pain  of  a  bad  sore  throat  is  much  less  severe  than  the 
pain  experienced  in  pleurisy,  pericarditis,  or  peritonitis,  and  yet  the 
number  of  sensitive  nerve-fibres  distributed  over  a  given  area  of  tissue  is 
many  times  greater  in  the  mucous  than  in  the  serous  membrane.  When 
the  tonsil  is  inflamed  the  pain  is  very  great,  but  it  depends  less  upon 
the  tension  of  the  mucous  membrane  covering  it  than  upon  stretching 
of  the  vessels  and  nerve-fibres  in  its  substance.  Again,  the  pain  we 
suffer  from  in  rheumatism  originates  in  tissues  which  are  rich  neither 
in  nerves  nor  vessels,  and  yet  it  is  more  severe  than  many  kinds  of 
pain,  the  seat  of  origin  of  which  is  in  parts  more  highly  vascular.  The 
pain  in  the  lungs  when  pulmonary  capillaries  are  congested,  even  if  they 
be  seriously  damaged,  is  slight  as  compared  with  that  which  results  when 
the  capillaries  of  the  pleura  are  involved.  Nerve-fibres  of  the  same  kind 
are  not  only  distributed  close  to  the  capillaries,  but  in  many  tissues,  as 
for  instance  the  cornea,  are  situated  at  some  distance  from  any  vessel ; 
but  these  nerve-fibres  belong  to  the  same  order  as  those  distributed  to 
capillaries,  and  act  as  afferent  nerves  to  centres,  the  efferent  nerves  of 
which  are  distributed  to  the  muscular  fibres  of  the  little  arteries.  It  is, 
I  believe,  when  these  afferent  fibres  are  made  to  act  violently,  that/^z'tf 
is  experienced. 

The  pain  associated  with  circumscribed  inflammation  of  various 
kinds  is  due  partly  to  the  stretching  and  pressure  to  which  the  fibres  of 
these  nerves  are  subjected,  and  partly  to  the  increased  nutrition  which 
proceeds  in  the  nerve  bioplasts,  in  consequence  of  the  increased  amount 
of  nutrient  pabulum  which  bathes  them,  and  which  has  transuded 
through  the  vascular  wall. 

Gastrodynia. — If  the  vessels  of  even  a  small  part  of  the  mucous 
membrane  of  the  stomach  become  unduly  distended  from  any  cause, 
discomfort  results.  If  there  is  too  much  action  of  the  glands  or  insuffi- 
cient action,  pain  in  the  stomach,  learnedly  called  Gastrodynia  (yaa-rjp, 
the  stomach,  and  btivvq,  pain),  or  Gastralgia  (dAyof,  pain),  is  occasioned. 

If  the  food  we  take  does  not  digest,  that  is,  if  it  does  not  gradually 
dissolve  after  it  reaches  the  stomach,  as  it  should  do,  but  remains  there, 
being  moved  round  and  round  by  the  muscular  action  of  the  organ,  we 
experience  pain — and  sometimes  extreme  pain.  If  you  take  rich,  im- 
proper food,  and  drink  a  quantity  of  bad  champagne,  more  especially  if 
your  dinner  comprises  tough  beef  and  concludes  with  a  good  supply  of 
heavy  pudding  or  pastry,  you  will  probably  learn  what  is  meant  by  an 
attack  of  gastrodynia,  unless  you  happen  to  have  an  unusually  vigorous 
digestion.  You  will  at  the  same  time  be  thoroughly  convinced  of  the 
existence  of  a  vast  number  of  extremely  sensitive  nerves  in  connection 
with  the  walls  of  your  stomach.  Not  only  so,  but  in  all  probability  the 
action  of  the  whole  intestinal  canal  will  soon  be  violently  disturbed,  and 
you  will  be  fortunate  if  you  get  off  with  a  sharp  attack  of  vomiting  and 

8JL 
* 


9O  HEARTBURN  OR  PYROSIS. 

active  diarrhoea :  for  in  this  way  you  may  perhaps  find  a  short  cut  to 
returning  health.  But  thousands  who  eat  moderately,  and  some  even 
who  eat  immoderately,  go  on  from  year  to  year  without  the  slightest 
discomfort  of  any  kind  in  any  part  of  the  intestinal  canal,  and  without 
discovering  from  any  sensations  they  experience  that  they  possess 
one. 

Indigestion  may  be  due  to  altered  gastric  juice,  or  to  the  secretion 
being  too  acid  or  not  sufficiently  acid ;  or  the  active  dissolving  substance, 
the  pepsin,  may  be  in  insufficient  quantity  or  imperfectly  formed;  or,  on 
the  other  hand,  the  derangement  may  depend  upon  the  pouring  into  the 
stomach  of  a  considerable  quantity  of  alkaline  fluid,  which  probably 
neutralizes  the  action  of  the  gastric  juice,  and  in  other  ways  impedes 
digestion  and  interferes  with  the  changes  taking  place  in  the  stomach. 
Strange  to  say,  two  fluids  of  opposite  qualities  are  secreted  by  glands  in 
different  parts  of  the  stomach. 

Heartburn,  Pyrosis,  or  Waterbrash, — There  are  certain  glands  at 
the  cardiac  extremity,  near  the  point  where  the  CEsophagus  opens  into 
the  stomach,  and  called  by  some  The  Cardiac  Glands,  the  secretion  of 
which  possesses  an  alkaline  reaction.  It  seems  that  these  glands  in  certain 
cases  secrete  a  great  quantity  of  a  clear,  somewhat  viscid,  alkaline  fluid. 
Few  of  us  are  aware  of  the  existence  of  the  secretion  of  these  cardiac 
glands  in  our  own  organisms,  nor  have  we  any  actual  experience  of  the 
formation  of  a  fluid  of  the  characters  just  mentioned.  As  is  well  known, 
the  contents  of  the  stomach,  under  ordinary  circumstances,  are  extremely 
acid,  and  many  suffer  from  the  regurgitation  from  time  to  time  of  a 
small  quantity  of  highly  acid  fluid  into  the  pharynx,  when  its  distinctly 
acid  taste  is  experienced.  Chalk  or  Magnesia  is  taken  for  the  relief  of 
the  Heartburn,  which,  when  physicians  thought  very  much  of  hard  words, 
was  known  as  Ardor  Ventriculi,  or  Cardialgia  (KapJmdAyof,  pain).  The 
acid  fluid  will  effervesce  freely  if  bicarbonate  of  potash  or  soda  be  added 
to  it.  A  similar  action  occurs  if  chalk  is  mixed  with  it,  but  as  it  is  more 
slow  the  effervescence  is  not  so  easily  observed. 

Some  of  the  Dispensary  patients  of  the  Hospital  will  tell  you  that  they 
frequently  reject  from  the  stomach  a  large  quantity  of  clear  liquid, 
which  you  will  find  will  cause  the  blue  color  of  reddened  litmus  to 
return.  It  is,  therefore,  of  alkaline,  not  acid,  reaction.  This  alkaline 
fluid  is  vomited  or  rejected  in  certain  cases,  which  are  termed  Water- 
brash  or  Pyrosis  (iri<pu<nc,  burning,  from  n-vp,  fire,  Per  Chaud  in  French). 
The  affection  is  very  common  in  Scotland,  and  in  England  there  are 
many  old  women  who  suffer  from  it.  Patients  sometimes  bring  us  a 
few  ounces  or  even  half  a  pint  or  more  of  alkaline  fluid.  Sometimes 
they  say  the  fluid  burns  them  as  it  comes  up.  In  other  cases  it  is 
described  as  slightly  salt,  or  mawkish,  or  tasteless.  The  secretion  when 
very  alkaline  neutralizes  the  acid  of  the  gastric  juice  if  it  is  not  rejected 


WATERBRASH:    TREATMENT.  gl 

soon  after  its  secretion,  and  greatly  impairs  the  digestion  of  albuminous 
matters. 

With  regard  to  the  acid  which  gives  its  reaction  to  the  gastric  juice. 
Although  this  consists  principally  of  Hydrochloric  acid,  it  must  be  borne 
in  mind  that  it  is  by  no  means  the  only  substance  present  having  an  acid 
reaction.  We  may  divide  the  acids  found  in  the  stomach  into  two 
classes : — i.  The  acids  formed  or,  at  any  rate,  secreted  there;  the  acid 
of  the  gastric  juice,  probably  hydrochloric  acid,  phosphoric  acid,  and 
lactic  acid ;  and,  2.  Acids  which  are  formed,  and  sometimes  in  large 
quantity,  too,  in  the  contents  of  the  stomach,  and  which  are  detrimental 
to  the  process  of  ordinary  digestion,  and  interfere  with  the  conversion  of 
albuminous  matter  into  peptones.  Valerian ic  and  Acetic  acids,  Formic 
acid,  Butyric  acid,  and  a  number  of  other  organic  acids,  seem  to  be 
produced  in  cases  in  which  digestion  is  much  deranged ;  and  it  is  aston- 
ishing, when  once  these  chemical  changes  have  been  initiated,  with  what 
persistence  they  continue,  in  spite  of  alterations  in  diet  and  various 
remedial  measures. 

Waterbrash  is  often  difficult  to  cure.  The  diet  must  be  carefully 
regulated,  so  that  the  work  of  the  stomach  may  be  uniformly  the  same 
for  each  meal.  Purgatives,  and  especially  preparations  of  Rhubarb,  are 
often  useful.  Magnesia,  Bismuth,  and  Ginger,  and  small  doses  of 
Opium  have  also  been  advocated.  Astringents,  such  as  Catechu  and 
Kino,  sometimes  do  good,  and  bitter  infusions,  particularly  Calumba, 
have  been  given  with  advantage.  Valerian,  Assafoetida,  and  Galbanum 
are  in  the  catalogue  of  medicines  that  may  be  prescribed  in  pyrosis,  but 
I  shall  presently  have  to  refer  to  the  treatment  of  dyspepsia,  and  shall 
bring  these  and  some  other  medicines  under  your  notice. 

In  many  of  the  cases  of  persistent  Heartburn  and  Indigestion,  too, 
much  food  has  been  taken  and  has  been  allowed  to  accumulate, in  the 
stomach.  As  it  is  not  possible  to  neutralize  organic  acids  which  are 
formed  by  the  decomposition  of  the  food,  without  at  the  same  time 
neutralizing  the  acid  of  the  gastric  juice,  it  is  often  useless  to  give 
alkalies.  Sometimes,  it  is  true,  benefit  does  result  from  the  use  of  this 
class  of  medicines.  By  more  than  neutralizing  all  the  acids  present,  an 
increased  secretion  of  gastric  juice  may  be  excited,  but  in  many  cases 
the  pathological  state  persists,  and  in  consequence  of  the  continuance  of 
the  processes  of  fermentation  and  decomposition,  fresh  quantities  of  the 
organic  acids  referred  to  are  set  free.  The  patient  gets  thin,  because  the 
greater  part  of  what  he  eats  is  resolved  into  compounds  which  fail  to 
nourish  him,  many  of  which  indeed  cannot  be  absorbed.  In  the  man- 
agement'of  these  cases  an  almost  forgotten  proceeding  is  obviously  the 
right  one.  First,  clear  out  the  stomach.  Give  an  emetic.  Vomiting 
is  the  natural  way  of  curing  many  cases  where  a  quantity  of  unusual 
organic  acids  is  formed.  Any  food  undergoing  chemical  decomposi- 


92  OF  THE    USE   OF  EMETICS. 

tion  in  the  stomach,  renders  healthy  digestion  for  a  time  impossible. 
The  normal  action  of  the  stomach  may  become  completely  impeded,  for 
decomposition  may  be  excited  in  every  form  of  nutrient  matter  intro- 
duced by  the  decomposing  substances  already  present.  People  may 
suffer  for  months  from  a  state  of  things  which  in  former  days  would 
have  been  cured  in  a  week  or  two  by  the  aid  of  emetics  and  purgatives. 
Remember,  then,  that  a  patient  may  actually  increase  in  weight  if  you 
cause  him  to  reject  the  contents  of  his  stomach  once  or  twice  a 
week.  Clear  out  the  stomach  from  time  to  time,  put  him  on  a  carefully 
regulated  diet  for  a  week  or  two,  and  his  sufferings  will  very  soon 
cease. 

Next,  as  to  the  emetic  you  should  employ.  Warm  water  will  answer 
in  many  cases.  You  tell  the  patient  to  take  two  or  three  or  more 
glasses  of  lukewarm  water  one  after  the  other.  The  stomach  gets 
distended,  nausea  is  experienced,  and  in  a-  few  minutes  the  greatest 
relief  is  afforded  by  vomiting  an  amount  of  acid  fermenting  matter 
which  astonishes  the  patient  and  convinces  him  that  the  proper  treat- 
ment has  been  adopted.  Some  persons  can  vomit  without  even  taking 
warm  water,  by  a  simple  effort  of  the  will ;  others  have  to  tickle  the 
fauces  and  the  soft  palate  with  the  finger.  Mustard  also  may  be  used 
to  excite  vomiting.  A  dessert-spoonful  of  the  ordinary  flour  of  mustard, 
mixed  with  half  a  pint  of  water,  will  make  most  persons  sick  in  a 
very  few  minutes.  Ipecacuanha  is  one  of  the  least  disagreeable  of 
emetics.  You  suspend  20  grains  of  powdered  Ipecacuanha  in  half  a 
tumbler  of  water,  and  direct  the  patient  to  drink  freely  of  lukewarm 
water  afterwards.  In  the  course  of  twenty  minutes  free  vomiting  will 
occur,  and  the  whole  of  the  contents  of  the  stomach  will  be  rejected 
without  pain  or  discomfort.  For  a  few  hours  after  the  emetic,  the  stomach 
may  be  allowed  to  rest.  Perhaps  some  desire  for  food  will  be  manifested, 
and  then  it  will  be  found  that  the  mucous  membrane  has  resumed  its 
normal  condition,  and  that  a  supply  of  healthy  gastric  juice  has  been 
formed  by  the  stomach  glands. 

Flatulence,  Wind  in  the  Stomach. — I  must  say  a  few  words  about 
flatulence  or  wind  in  the  stomach — a  somewhat  disagreeable  digestive 
derangement  which  depends  in  some  cases  upon  unusual  decomposition 
going  on  in  the  food,  and  in  some  cases  probably  upon  the  actual 
separation  of  gases  from  the  blood,  or  their  secretion  into  the  stomach 
or  other  part  of  the  alimentary  canal  by  some  of  the  glands  of  the 
mucous  membrane.  Some  unfortunate  persons  seem  to  have  a  baneful 
predisposition  to  inflation,  and  are  habitually  troubled  with  an  enormous 
quantity  of  gas  in  the  stomach.  The  organ  is  invariably  greatly  dis- 
tended, and  I  am  sure,  in  some  of  the  cases  that  have  come  under  my 
notice,  the  stomach  must  have  frequently  contained  two  or  three  quarts 
of  gas  besides  more  solid  contents,  and  this  not  now  and  then,  but  con- 


FLATULENT  CROAKINGS.  93 

stantly  for  weeks  or  months,  this  state  of  distention  being  in  fact  the 
general  condition. 

It  has  been  supposed  that  the  peculiar  knocks  and  taps  characteristic 
of  certain  spiritual  manifestations  may  be  due  to  the  movement  of  gas 
from  one  part  of  the  stomach  to  another,  or  from  the  stomach  into  the 
intestines.  But  if  in  few  instances  these  flatulent  croakings  are  under 
the  influence  of  spirits  or  take  place  in  obedience  to  the  will,  there  is 
no  doubt  that  in  the  great  majority  of  instances  they  occur  in  spite  of 
the  strongest  voluntary  efforts  to  restrain  them.  The  gas  is  moved  about 
in  the  stomach  and  intestinal  canal  by  the  action  of  the  muscular  fibres, 
and  in  the  most  capricious  manner.  Borborygmi  (popfiopvSu,  I  make  a 
dull  noise)  are  a  serious  annoyance,  and  on  occasions  a  misfortune,  as, 
for  instance,  when  they  trouble  the  sufferer  in  a  select  company  during 
a  pause  in  general  conversation.  It  is  a  very  common  ailment,  and 
people  often  complain  that  they  have  wind  in  the  stomach  or  bowels, 
and  much  desire  to  be  relieved.  You  must,  therefore,  pay  attention  to 
the  matter,  and  study  the  circumstances  favorable  to  the  development 
of  the  unpleasant  phenomenon,  and  the  methods  by  the  help  of  which 
you  may  be  afcle  to  give  relief.  Sometimes  by  setting  right  the  process 
of  digestion,  you  may  cure  the  patient.  Pepsine  alone  continued  for  a 
week  or  two  sometimes  relieves.  In  very  obstinate  cases,  occurring  in 
people  who  live  too  freely,  it  may  be  necessary  to  begin  with  an  emetic, 
followed  up  by  a  restricted  diet  for  some  weeks.  Sometimes  a  single 
emetic  will  effect  a  complete  cure. 

Another  very  valuable  remedial  measure  consists  in  purgation.  You 
give  a  smart  purge,  say  a  three-grain  Calomel  pill,  at  night,  and  on  the 
following  morning  a  black  draught  or  some  Sulphate  and  Carbonate  of 
Magnesia  in  Peppermint  -water  with  a  little  ginger.  In  this-  way  the 
contents  of  the  alimentary  canal  are  got  rid  of.  After  careful  dieting 
for  a  time  the  patient  completely  recovers.  In  not  a  few  cases  you  may 
relieve  these  •symptoms  by  mitigated  starvation.  Of  course,  if  a  patient 
came  to  you  and  you  advised  him  to  starve  himself,  you  would  never  see 
him  again.  But  there  are  many  ways  of  inculcating  good  advice  with- 
out shocking  the  nerves  of  sensitive  people  who  suppose  that  abstinence 
from  food  for  a  few  hours  means  death.  Tell  your  patient  not  to  take 
any  solid  food  for  a  week.  Order  him  a  little  beef-tea  three  times  a  day. 
Towards  evening  he  may  take  with  it  a  biscuit  or  a  little  dry  toast.  If 
very  hungry  you  may  permit  him  to  have  a  little  bread  and  butter,  but 
a  cup  of  lentil  gruel  will  be  better  for  him,  and  will  be  found  more  satis- 
fying. By  a  little  exercise  of  ingenuity  you  may  suggest  various  things 
to  take  that  will  satisfy  him,  but  which  altogether  will  not  amount  to 
much.  In  this  way,  in  the  course  of  a  few  days,  the  effect  desired  will 
have  been  accomplished.  You  permit  as  little  matter  as  possible  to  pass 
into  the  alimentary  canal  for  a  time.  Some  prefer  to  be  ordered  to  have 


94  TREATMENT  OF  INDIGESTION. 

nothing  but  oatmeal  or  lentil  gruel  for  a  few  days.  The  last  is  a  really 
valuable  thing.  It  is  nutritious,  satisfying,  and  acts  as  a  sort  of  soothing 
poultice  to  the  stomach  and  intestinal  canal.  Tell  the  patient  to  live  on 
this  or  on  Revalenta  Arabica  if  he  prefers  it  for  three  or  four  days,  and 
in  this  way  you  will  probably  get  the  action  of  the  stomach  and  bowels 
right,  and  completely  relieve  all  dyspeptic  symptoms.  The  flatus  from 
which  the  patient  had  long  been  suffering  will  be  no  more  generated. 

General  Observations  on  the  Treatment  of  Ordinary  Forms  of  Indi- 
gestion.— I  shall  not  pretend  to  discuss  this  large  subject  exhaustively, 
but  endeavor  rather  to  direct  your  attention  to  some  general  remedial 
measures  which  you  will  find  useful  in  your  practice.  Sometimes  there 
is  actual  discomfort  when  the  stomach  does  not  digest  the  food  as  rap- 
idly as  it  ought  to  do.  The  patient  feels  full  and  uneasy  for  several 
hours  after  a  meal  has  been  taken.  Very  commonly  under  these  cir- 
cumstances sleep  is  disturbed,  or  perhaps  cannot  be  obtained.  Those 
who  dine  too  late  in  the  evening  often  find  that  the  stomach  does  not 
work  well.  The  food  in  consequence  long  remains  in  the  organ  in  an 
undigested  state.  It  is  being  continually  moved  about  and  worked  up 
by  the  unceasing  contraction  of  the  muscular  coat  of  the'stdmach,  but 
still  its  volume  is  but  little  changed,  and  the  stomach  remains  much 
distended.  A  feeling  of  general  discomfort  results,  which  interferes 
with  sleep.  This,  in  fact,  is  a  very  common  cause  of  wakefulness.  The 
patient  in  consequence  soon  becomes  weak,  feels  fagged,  and  unable  to 
work.  The  sense  of  lassitude,  and  failure,  and  sometimes  extreme 
despondency,  suggests  to  him  the  need  of  "support."  Friends  advise 
him  to  partake  more  freely  of  nutritious  food.  Port  wine,  turtle  and 
oxtail  soup,  and  other  highly  nutritious  delicacies  are  wasted  upon  him ; 
for  instead  of  improving  he  gets  worse,  and  feels  more  ill  and  unfit  for 
business  than  ever.  Knowing  the  importance  of  rest  he  flies  to  sopo- 
rifics, takes  Chlorodyne,  Nepenthe,  or  Chloral  and  thus  possibly,  in  ad- 
dition to  his  many  troubles,  experiences  a  terrible  headache,  tremor  of 
muscles,  general  "nervousness"  which  never  before  troubled  him,  and 
dread  of  impending  failure  of  health.  He  tells  you  that  he  really  feels 
very  ill  indeed.  But  a  few  inquiries  and  a  little  consideration  on  your 
part  enable  you  to  afford  speedy  relief.  A  mercurial  purge,  followed  by 
a  few  doses  of  some  gentle  laxative,  will  soon  cause  all  the  more  serious 
symptoms  to  disappear,  and  then  you  must  attend  to  the  digestive  pro- 
cess. Diet  the  patient  carefully,  only  allowing  easily  digestible  sub- 
stances, and  in  very  moderate  quantity  for  a  week.  A  single  purgative 
dose  may  not  suffice.  You  must  bear  in  mind  that  in  many  of  these  cases 
the  muscular  action  of  the  stomach  and  small  intestines,  or  the  sensitive 
surface  which  plays  an  important  part  in  the  reflex  action,  is  at  fault,  and 
medicines  which  encourage  the  muscular  contraction  and  the  driving 
down  of  the  intestinal  contents  may  be  required.  Castor  oil,  Rhubarb, 


MEDICINES  OF  USE  IN  INDIGESTION.  $$ 

in  powder  or  in  pills,  Colocynth,  Podophyllin,  are  often  of  great  use  in 
some  of  these  cases ;  but  as  I  shall  have  to  consider  their  action  under 
the  head  of  purgatives,  I  need  not  say  more  here.  Advise  the  patient 
to  take  small  doses  of  Dilute  Hydrochloric  acid  (fifteen  or  twenty  drops, 
in  two  tablespoonfuls  of  water),  half  an  hour  before  food,  and  his 
digestion  will  soon  be  restored.  Hydrochloric  acid  is,  as  you  know,  the 
natural  acid  of  the  gastric  juice,  and  if  you  continue  to  give  it  for  some 
time,  you  will  find  great  improvement,  not  only  in  the  digestive  power  of 
the  stomach,  but  in  the  performance  of  their  function  by  other  parts  of 
the  alimentary  canal.  You  must  not  forget  that  from  ten  to  twenty  drops 
of  this  acid  in  water  before  meals  is  also  of  great  use  in  treating  very 
many  cases  of  weak  digestion.  And  Acids  of  various  kinds  are  valuable 
in  many  forms  of  dyspepsia.  The  dilute  Hydrochloric  acid,  Acidum 
Hydro  chloric  um  dilutum,  and  the  Nitro-hydrochloric  acid,  Acidum 
Nitrohydrochloricum  dilutum,  are  most  useful,  and  by  their  aid  you  may 
cure  many  a  patient.  There  is  more  than  one  distinguished  physician 
in  London,  whose  reputation,  it  may  almost  be  said,  has  been  gained 
by  ordering  acids.  There  can  be  no  doubt  of  the  efficacy  of  these 
medicines.  Phosphoric  acid,  the  Acidum  Phosphoricum  dilutum,  in 
doses  of  twenty  drops  in  water,  seems  to  suit  some  people  better  than 
the  other  mineral  acids.  Lactic  acid  has  also  been  described  ;  but  upon 
the  whole  I  think  you  will  find  the  acids  first  mentioned  very  efficacious. 
If  you  give  from  fifteen  to  twenty  minims  of  the  dilute  Nitro-hydro- 
chloric acid,  with  half  a  drachm  of  Tincture  of  Orange,  Tinctura 
Aurantii,  a  like  quantity  of  the  Syrup  of  Lemon,  Syrupus  Limonis,  and 
perhaps  ten  drops  of  Chloric  Ether,  Spiritus  Chloroformi,  with  an  ounce, 
or  an  ounce  and  a  half  of  water, — you  will  prescribe  a  dose  which  will 
please  your  patients,  and  will  be  of  great  service  to  them.  The  mixture 
should  be  taken  twenty  minutes  or  half  an  hour  before  food  twice  or 
three  times  a  day.  In  some  cases  it  is  well  to  add  ten  drops  of  Tincture 
of  Ginger.  I  have  known  people  continue  a  mixture  of  this  sort  for 
six  or  seven  months  at  a  time,  and  with  great  benefit.  It  is  well  to 
encourage  them  to  give  it  up  now  and  then  for  a  week  or  so,  but  if  they 
persist,  it  can  do  no  harm,  and  may  possibly  deter  them  from  indulging 
in  alcohol.  Lemon  juice,  Citric  Acid,  the.  Acid  Tartrate  of  Potash, 
Potasses  Tartras  Adda,  and  other  organic  acids  and  acid  salts,  have 
also  been  found  of  great  use  in  the  treatment  of  these  cases. 

If  decomposition  take  place  in  some  of  the  constituents  of  the  food 
after  it  has  been  some  time  in.  the  stomach,  instead  of  the  ordinary 
solvent  action  proceeding  until  complete  solution  is  effected,  as  I  have 
already  said,  a  large  quantity  of  fetid  gas  may  be  generated.  In  these 
cases  you  will  sometimes  find  benefit  will  result  from  an  opposite  plan 
of  treatment — from  alkalies  instead  of  acids.  The  alkali  is  usually 
given  after  food,  but  I  have  found  that  in  some  instances  where  gas  is 


96  INDIGESTION:    TREATMENT. 

generated  in  qliantity  after  food  is  taken,  it  is  advantageous  to  give  it 
about  ten  minutes  before  food.  You  may  order  twenty  drops  of  Liquor 
Potassse  and  ten  drops  of  Tincture  of  Ginger  in  water.  Sometimes 
you  will  find  that  five  minims  of  Liquor  Ammonias  will  answer  better 
than  the  Liquor  Potassse.  It  is  probable  that  the  alkali  acts  by  exciting 
the  secretion  of  an  excess  of  acid  which  at  once  exerts  a  solvent  action 
upon  the  meat  and  allied  substances.  The  condition  we  are  speaking 
of  may  sometimes  be  relieved  by  taking  a  stimulant  remedy  which 
excites  a  free  secretion  of  gastric  juice,  such  as  brandy,  or  ginger,  or 
pepper,  without  giving  alkali  at  all. 

In  some  obstinate  cases  the  plan  of  giving  Hydrochloric  acid  before 
meals,  and  Carbonate  of  Soda,  or  Potash,  or  Liquor  Potassse,  or  Liquor 
Ammonise  after  meals,  has  succeeded  after  many  other  modes  of  treat- 
ment had  completely  failed.  If  I  want  to  give  an  ordinary  alkali,  I 
often  prescribe  twenty  grains  or  more  of  Bicarbonate  of  Soda,  Soda 
Bicarbonas,  in  an  ounce  of  water.  You  may  order  Peppermint,  or 
Pimento,  or  Cinnamon  water,  Aqua  Menth<z  Piperttce,  Aqua  Pimento, 
Aqua  Cinnamomi,  as  you  may  think  best,  and  you  will  find  that  two 
or  three  drops  of  Dilute  Hydrocyanic  Acid,  Acidum  Hydrocyanicum 
dilutum,  and  a  few  drops  of  Tincture  of  Ginger,  Tinctura  Zingiberis, 
will  improve  the  dose.  Some  physicians  prefer  Bicarbonate  of  Potash, 
but  Liquor  Potassae  is,  in  my  opinion,  better  than  either,  at  least  in 
many  cases,  and  Liquor  Ammonia  may  be  of  use  in  cases  in  which 
other  alkaline  remedies  do  not  agree. 

Preparations  of  Bismuth,  too,  are  often  very  useful.  You  may  order 
from  five  to  twenty  grains  of  the  old  Nitrate  of  Bismuth,  Bismuthi 
Subnilras  of  our  Pharmacopoeia,  or  about  the  same  quantity  of  the  Car- 
bonate of  Bismuth,  Bismuthi  Carbonas,  suspended  in  an  ounce  of 
water  by  the  help  of  a  little  mucilage,  and  flavored  with  Ginger, 
Peppermint,  or  some  such  substance.  Or  you  may  choose  one  of  the 
more  elegant  preparations  of  Bismuth,  of  which  so  many  are  now  made. 
We  have  a  solution  of  Citrate  of  Bismuth  and  Ammonia,  Liquor 
Bismuthi  et  Ammonia  Citratis,  in  the  Pharmacopoeia,  which  contains 
three  grains  of  Oxide  of  Bismuth  in  a  drachm,  and  of  which  a  dose  of 
from  half  a  drachm  to  a  drachm  may  be  given  in  a  diluted  state.  Many 
other  solutions  of  Bismuth  supposed  to  be  improvements  upon  this 
have  been  recommended.  Bismuth  lozenges,  Trochisci  (rpo^of,  a  wheel) 
Bismuthi,  are  also  a  convenient  form  in  which  to  give  this  remedy. 

Preparations  of  Iron,  Arsenic,  and  Zinc  in  small  doses  are  of  value 
in  some  instances,  and  when  the  mucous  membrane  is  unduly  sensitive 
and  irritable,  you  will  find  that  small  doses  of  Conium,  Hyoscyamus, 
Morphia,  or  Opium  will  do  more  good  than  anything;  but  of  these  I 
shall  have  to  speak  in  another  place. 

External  applications  are  sometimes  beneficial.     Stimulating   lini- 


FLATULENT  CROAK  INGS.  97 

ments  may  be  gently  rubbed  on  the  skin  over  the  region  of  the  stomach. 
Sedative  applications  externally  are  also  often  recommended.  A  Bella- 
donna or  Opium  plaster  will  cure  some  persons,  while  others  derive  more 
benefit  from  ordinary  counter-irritants.  A  mustard  poultice,  a  poultice 
consisting  of  equal  parts  of  mustard  flour  and  linseed  meal,  or  a 
mustard  leaf,  a  piece  of  wet  writing  paper  being  interposed  between  the 
mustard  and  the  skin,  is  often  tried  with  advantage.  And  you  must 
not  forget  the  very  simple  and  efficacious  measure  of  applying  wet  rag 
covered  with  oiled  silk,  or  a  piece  of  Spongio-piline,  moistened  and 
worn  over  the  upper  part  of  the -abdomen  for  two  or  three  hours  daily. 
This  is  pleasant  to  wear.  It  is  soothing,  and  often  useful. 

In  cases  of  very  obstinate  flatulent  indigestion  accompanied  by 
unpleasant  explosions  and  croakings  (Borborygmi),  advantage  may 
result  from  the  use  of  pungent  substances,  like  Horseradish,  Peppers  of 
various  kinds,  as  well  as  Ginger.  The  Compound  Spirits  of  Horse- 
radish, the  Spiritus  Armoracice  Compositus  of  the  Pharmacopoeia,  is  not 
used  now  as  it  used  to  be ;  but  it  is  well  to  bear  it  in  mind,  for  it  is  a 
very  useful  preparation.  You  may  order  half  a  drachm  or  more  in  an 
alkaline  or  acid  mixture,  or  with  one  of  the  preparations  of  bismuth 
above  mentioned. 

As  to  condiments  -generally,  I  would  remark  that  if  taken  with 
judgment,  and  only  occasionally,  they  do  no  harm,  and  most  persons  as 
they  advance  in  years  indulge  in  them  more  or  less,  but  it  is  bad  in 
many  ways  for  a  patient  to  get  into  the  habit  of  taking  very  strong 
peppers,  for  after  a  time  the  stomach  fails  to  work  without  its  artificial 
stimulus,  and  may  become  very  weak  indeed.  Unquestionably,  as 
regards  children  and  young  people,  we  may  be  quite  sure  that  "Fames 
condimentum  optimum  est ; "  but  as  we  get  older  and  gradually 
become  more  dominated  by  the  customs  indulged  in  by  the  more 
fortunate  of  our  friends  and  approved  by  the  rest,  our  appetite  becomes 
less,  and  perhaps  we  almost  forget  what  it  is  to  feel  hungry.  We  begin 
to  appreciate  delicate  flavors,  and  to  learn  to  like  sauces.  Sapid 
materials  are  desired,  and  often  too  freely  indulged  in,  until  we  arrive  at 
that  high  pitch  of  degradation,  liking  and  longing  for  delicate  viands,— 
desirous  of  dining  daily,  and  giving  our  hearts  to  friends  who  are  rich 
enough  to  possess  a  skilful  cook  and  an  extensive  larder. 

Few  men  are  more  injudicious  in  the  management  of  their  digestive 
organs  than  well-to-do  Englishmen.  Not  a  few  who  go  to  India  and 
other  hot  climates,  in  defiance  of  reason,  actually  live  as  they  have  been 
accustomed  to  live  here.  They  tell  you  they  must  daily  have  their  good 
meat  meal,  or  would  certainly  lose  strength.  They  cannot  digest  as 
much  meat  as  they  like  to  swallow,  so  they  get  into  the  way  of  taking 
large  quantities  of  pepper.  Curry,  which  is  a  mixture  of  pungent  seeds 
and  peppers  ground  very  fine,  is  very  popular.  No  doubt  it  is 
9  G 


98  DIET  AV  HOT  CLIMATES. 

appetizing,  and  the  flavor  of  a  well-made  curry  is  certainly  pleasant  to 
the  palate  of  most  persons — even  to  those  who  have  no  pretension  to 
be  considered  epicures,  or  good  judges  of  delicacies.  But  this  mixture, 
curry,  has  become  a  very  favorite  dish  with  Europeans  who  live  in 
India  and  other  hot  climates  on  account  of  its  stimulating  action,  and 
because  it  helps  the  stomach  to  digest  a  greater  quantity  of  meat  than 
could  be  properly  dissolved  and  absorbed  without  its  aid.  Our  system 
of  dining  off  a  number  of  rich  meats,  as  many  do  day  after  day,  is  bad 
enough,  and  damaging  to  the  organism  in  this  cold,  damp,  changeable 
climate,  but  in  the  hot  parts  of  the  world  the  practice  is  disastrous. 
There,  diet  should  be  light,  and  should  consist  principally  of  vegetable 
matter.  Too  many  consider  that  if  they  do  not  take  much  meat  they 
must  take  much  beer,  and  not  a  few  will  insist  on  damaging  their 
stomachs  with  liqueurs  or  brandy  and  brandied  wines.  Derangement 
is  soon  followed  by  serious  illness.  The  liver,  kidneys,  and  all  parts  of 
the  alimentary  canal  become  highly  congested,  and  weeks  or  months  of 
rest  and  carefully  regulated  very  moderate  diet  are  necessary  to  gain  for 
the  patient  a  valetudinarian  existence.  Every  one  going  to  a  hot 
climate  should  study  physiology  sufficiently  to  understand  the  impor- 
tance of  living  according  to  reason,  and  the  penalties  that  must  be  paid 
for  indulgence.  Let  him  draw  conclusions  from  what  he  observes  con- 
cerning the  food  of  the  people  around  him.  He  may  take  fruits  and 
vegetables,  farinaceous  matter  of  various  kinds,  milk  and  eggs,  and  just 
meat  enough  to  satisfy  his  prejudices  in  favor  of  that  kind  of  food. 
But  he  will  be  very  unwise  if  he  allow  himself  to  get  into  the  way  of 
constantly  stimulating  the  gastric  and  other  glands  by  strong  peppers  in 
order  that  the  undue  action  required  for  the  digestion  of  considerable 
quantities  of  meat  may  be  established. 

Those  who  come  from  a  hot  to  a  temperate  or  cold  climate  will  do 
well  to  modify  their  diet.  They  should  consume  more  butter,  or  cream, 
and  milk  than  they  would  desire  or  find  agreeable  in  a  warm  climate; 
the  quantity  of  meat  may  be  increased,  and  possibly  some  will  find 
benefit  from  taking  a  little  alcohol.  Alcohol,  though  apparently 
desirable  in  the  case  of  some  persons  living  in  cold  climates,  is  very 
deleterious  in  hot  ones.  It  is  a  remedy  which  is  often  employed  in 
certain  forms  of  dyspepsia,  but  it  is  a  dangerous  one.  Drinking  habits 
are  easily  acquired,  and  although  a  little  alcohol  will  often  remove  dis- 
comfort and  assist  digestion,  many  find  that  after  a  time  they  cannot 
digest  without  it,  and  not  only  so,  but  gradually  increasing  doses  are 
taken  as  they  find  the  small  ones  fail  to  have  the  desired  effect.  It  is 
far  better  to  suffer  slight  indigestion  and  discomfort  than  by  imbibing  too 
much  alcohol  to  run  the  risk  of  bringing  on  a  worse  form  of  dyspepsia 
due  to  structural  changes  in  the  stomach  and  liver,  which  lead  to  far 
wider  and  more  serious  morbid  changes  in  various  tissues. 


INSUFFICIENT  CLOTHING  AND  INDIGESTION.  99 

Although  in  winter  digestion  is  often  very  good,  and  not  un- 
commonly weak  stomachs  work  better  in  cold  than  they  do  in  hot 
weather,  there  can  be  no  doubt  that  some  of  the  most  obstinate  forms 
of  indigestion  arise  from  the  body  not  being  sufficiently  protected. 
Those  who  adopt  light  clothing  in  an  ungenial  climate  are  very  likely  to 
suffer,  and  I  feel  pretty  confident  that,  next  to  injudicious  eating  and 
drinking,  injudicious  clothing  is  the  commonest  cause  of  various  dis- 
orders, among  which  are  some  of  the  most  serious  we  have  to  treat. 
The  fear  people  express  of  being  too  thickly  clad  in  this  climate  would 
be  ludicrous  if  the  consequences  were  not  often  so  serious.  The  young 
of  both  sexes  are  the  chief  offenders  in  this  particular,  and  many  an 
attack  of  rheumatic  fever,  of  bronchitis,  of  pneumonia,  and  of  other 
serious  maladies,  has  been  due  to  light  clothing.  Now,  although  I  admit 
that  woollen  material  of  the  thickness  suitable  for  those  who  live  in  such 
a  climate  as  this,  is  uncomfortable,  nay,  disagreeable,  for  perhaps  a  fort- 
night or  three  weeks  in  some  summers,  I  have  never  known  any  illness 
brought  on  by  the  practice.  To  be  bathed  in  perspiration  from  morning 
to  night  and  from  night  to  morning  is  not  pleasant,  but  neither  is  it 
dangerous,  and  it  is  better  to  endure  such  discomfort  during  our  short 
summer  than  run  the  risk  of  taking  cold  in  consequence  of  a  change  in 
the  weather  finding  us  insufficiently  protected.  Not  a  summer  passes 
but  we  have  to  treat  a  number  of  cases  of  illness  brought  on  by  in- 
sufficient clothing,  and  among  them  will  be  a  few  cases  of  phthisis  and 
other  affections  which  after  a  time  destroy  life.  Depend  upon  it, 
people  had  better  clothe  very  warmly  in  winter  and  not  change  their 
clothing  in  the  summer,  than  be  insufficiently  protected  during  the 
chilly  days  which  occur  even  during  the  hottest  period  of  the  year.  I 
should  say  woollen  should  be  always  worn  next  the  skin  by  all,  though 
in  the  hottest  weather  it  may  be  somewhat  thinner  than  in  the  winter. 
Of  course  you  do  find  exceptional  people  who  do, not  need  this,  just 
as  you  find  people  who  eat  and  drink  enormously  without  paying  any 
penalty  for  their  excesses;  but  we  must  advise  persons  as  if  they  were 
average  organisms — not  remarkable  exceptions.  In  strongly  recom- 
mending a  very  decided  additional  protection  to  the  delicate  nerves 
and  vessels  of  the  skin  to  that  afforded  by  the  thin  epidermis  (em,  upon, 
Jfp/^a,  the  skin),  which  forms  a  very  essential  and  absolutely  necessary 
part  of  us,  I  confess  to  one  considerable  difficulty,  and  this  is  to  name 
the  material  which  may  be  worn  by  every  one  without  discomfort.  It  is 
curious  that  with  all  the  ingenuity  exhibited  in  the  woollen  manufacture 
no  texture  has  yet  been  invented  to  wear  next  the  skin  which  is  wholly 
satisfactory  and  cheap.  Nothing  I  believe  is  yet  to  be  obtained  better 
than  good  flannel,  but  it  is  practically  difficult  to  get  flannel  garments 
made  to  fit  comfortably ;  and  unless  great  care  be  taken  to  shrink  the 
flannel  thoroughly  before  it  is  used,  uncomfortable  diminution  in  ail 


IOO  INDIGESTION  IN  OLD  AGE. 

directions  will  soon  be  manifest,  and  will  progress  to  a  degree  which  is 
most  inconvenient.  The  ordinary  woven  goods  are  still  worse  in  this 
respect,  and  those  who  purchase  things  to  fit  them  find  in  the  course  of 
a  few  months  that  they  are  so  small  as  to  be  unwearable.  Nevertheless, 
you  must  advise  your  patients  of  both  sexes  to  wear  woollen  of  some 
kind  next  the  skin.  For  the  weak  and  sensitive  this  protection  is  ab- 
solutely necessary,  and  the  strong  and  healthy  will,  by  adopting  this 
course,  escape  many  small  derangements.  Wash  leather  has  been 
recommended.  It  is  comfortable,  but  too  warm  during  the  greater  part 
of  the  year.  Like  silk,  it  is  very  expensive,  and  there  are  other  objec- 
tions to  its  use  which  I  need  not  describe  in  detail.  Upon  the  whole, 
as  I  have  said,  good  soft  flannel  is  probably  the  best  texture  yet  made 
for  wearing  next  the  skin,  but  if  people  absolutely  object  to  flannel, 
you  must  advise  them  to  wear  silk,  or  some  very  thin,  unirritating 
material  under  the  flannel.  Those  who  wear  woollen  under-clothes 
may  go  out  in  all  weathers,  and  will  not  require  the  very  heavy  and 
oppressive  overcoats  which  are  such  an  encumbrance  in  walking. 

Indigestion  from  Failing  Glands,  as  in  Old  Age. — But  there  are 
cases  in  which  the  stomach  loses  its  power.  The  action  becomes 
weaker.  The  glands  require  some  artificial  stimulus  to  excite  them  to 
discharge  the  proper  amount  of  work.  As  we  get  older  we  become  more 
particular  as  regards  the  flavor  and  other  characters  of  what  we  eat 
and  drink,  and  many  cease  to  feel  that  desire  for  food,  that  pleasant 
feeling  of  hunger,  which  is  worth  more  than  perfection  in  cibo-critical 
powers.  As  a  general  rule,  you  notice  that  gentlemen  over  forty  are 
more  particular  as  regards  their  dinners  than  gentlemen  of  twenty-one, 
while  even  working-men  of  fifty  or  sixty  years  of  age  look  upon  a  quiet 
good  dinner  as  a  very  important  and  not  unpleasant  portion  of  the 
daily  round  of  life.  A  boy  or  a  young  man  in  perfect  health  and 
vigor  digests  without  knowing  that  he  possesses  digestive  organs,  but  if 
the  stomach  becomes  weak  its  owner  gets  particular,  and  the  food  he 
eats  must  be  nicer  as  well  as  more  digestible.  And  so  it  comes  about 
that  increased  interest  is  taken  in  cooker}'-,  and  the  cook  becomes  a 
person  of  the  highest  consequence.  In  old  age  the  stomach  often 
Nreomes  so  weak  that  only  certain  well-cooked  and  very  delicate  things 
,  ~  digested,  Sometimes  the  stomach  fails  altogether,  and  we  have 
Carious  expedients  in  feeding,  if  we  are  to  succeed  in  keeping 

f  ' 

old  patients  a  uve- 

You  must  also  bear  in  mind  that  a  ver^  common  cause  of  indlges- 
tion  in  advanced  age,  and  in  but  too  many  instances  long  before,  is  the 
failure  to  perform  their  office  on  the  part  of  the  natural  comminutors  of 
the  food  The  teeth,  from  defective  formation  and  growth  during  the 
early  period  of  life,  have  nearly  worn  away,  or  they  have  decayed,  or 
perchance  the  gum  has  altered  in  structure  and  the  teeth  have  dropped 


SCHOOL 

t*r-: 
•DEFECTIVE  MASTICATION.  IOI 

out.  The  consequence  is  that  practically  there  is  no  proper  mastica- 
tion, the  food  is  very  imperfectly  subdivided,  and  far  too  little  saliva  is 
mixed  with  it.  Often  it  is  bolted,  and  the  large  hard  masses  which 
reach  the  stomach  cannot  be  properly  acted  upon.  It  is  often  neces- 
sary to  ask  a  patient  whether  he  is  able  to  bite. 

If,  as  sometimes  happens,  the  food  passes  into  the  stomach  in  boluses 
of  considerable  size,  but  a  small  portion,  in  fact,  only  the  surface  of 
each  mass  can  be  subject  to  the  action  of  the  gastric  juice,  and  if  the 
meal  is  a  large  one,  a  very  small  portion  only  will  be  properly  digested. 
The  rest  gradually  passes  onwards  in  a  state  not  fit  for  absorption,  or  it 
remains  in  the  stomach  until  the  next  meal  is  taken,  and  increases  the 
confusion  and  disturbance.  Do  not  forget  that  many  cases  of  imperfect 
digestion  depend  upon  the  bad  state  of  the  teeth.  If  you  do  not  find 
this  out  you  may  go  on  prescribing  a  number  of  useless  remedies,  to  the 
disappointment  of  your  patient  and  to  the  loss  of  your  credit.  There 
are  people  even  under  thirty  who  are  incompetent,  from  a  dental  point 
of  view.  Happily  the  condition  is  a  remediable  one,  and  the  new 
organs  which  can  be  supplied  by  art,  are  in  some  cases  superior  to  those 
developed  by  nature  operating  under  the  sad  disadvantages  needlessly 
imposed  by  the  ignorance  and  wickedness  of  man.  A  patient  may  be 
provided  with  artificial  teeth  which  will  work  better  than  his  own, 
though  he  may  have  to  surfer  some  unpleasant  twinges  before  his  mouth 
is  set  right  for  mastication  under  the  new  circumstances.  When,  there- 
fore, you  are  consulted  about  difficult  or  weak  digestion,  or  indigestion, 
it  is  very  necessary  to  examine  the  mouth  with  the  view  of  ascertaining 
the  general  state  of  the  teeth,  and  of  determining  whether  the  patient 
can  or  cannot  properly  masticate. 

And  now  let  me  revert  to  those  cases  where  the  digestive  power  of 
the  stomach  becomes  weak  because  the  gastric  glands  have  gradually 
wasted,  and  are  perhaps  shrivelled  and  incapable  of  secreting  gastric 
juice  either  good  in  quality  or  sufficient  in  quantity.  When  one  con- 
siders the  immense  quantity,  amounting  perhaps  to  ten  or  more  pounds, 
of  gastric  juice  formed  during  every  period  of  twenty-four  hours,  one 
cannot  wonder  that  the  secretion  should  diminish  as  the  vigor  of  life 
becomes  impaired  and  reduced.  As  age  advances  the  action  of  the 
gland-cells  gets  more  feeble  and  the  secretion  is  more  slowly  formed. 
The  glands  participate  in  the  general  shrinking  and  wasting  and  change 
into  connective  tissue,  which  goes  on  in  other  organs  and  interferes 
with  the  due  discharge  of  their  functions. 

If  digestion  is  impaired,  the  proper  amount  of  nourishment  absorbed 
will  be  less  than  is  required,  and  persons  who  suffer  for  some  time  grad- 
ually become  weak.  The  muscles  lose  their  vigor  and  the  tissues  gen- 
erally suffer.  Much  of  their  substance  is  absorbed,  and  in  some  cases 
there  is  considerable  wasting.  Patients  frequently  get  perceptibly  thinner 
9* 


102  PEPSINE    THE  DIGESTING  SUBSTANCE. 

and  become  unable  to  properly  discharge  their  usual  duties.  In  too 
many  instances,  in  consequence  of  such  phenomena  going  on  for  a  con- 
siderable time,  the  organism  loses  its  power  of  resistance  to  adverse 
circumstances,  and  the  patient  becomes  liable  to  special  morbid  changes, 
affecting  lungs,  liver,  or  kidneys,  and  may  suffer  from  intercurrent 
maladies,  which  may  cut  short  life.  A  state  of  weak  health  may  be 
engendered,  the  blood  becoming  much  altered  in  quality ;  and  not 
unfrequently  morbid  conditions  are  developed,  which  are  known  to  be 
due  to  an  unhealthy  state  of  the  circulating  fluid.  The  blood  may 
coagulate  in  capillary  vessels  and  small  veins ;  and  in  the  changes  re- 
sulting from  the  stagnation,  substances  are  formed  which,  re-entering 
the  blood,  may  poison  or  otherwise  damage  the  system.  In  short,  the 
most  complex  changes,  and  serious  forms  of  disease,  may  be  dependent 
upon  long-continued  imperfect  action  of  the  stomach  and  upper  part 
of  the  bowels. 

You  may  often  improve  digestion  by  giving  those  acids  which  I  have 
before  referred  to.  Even  where  there  is  a  gouty  tendency,  and  you 
would  be  disposed  to  prefer  alkaline  to  acid  remedies,  you  will  not  un- 
frequently find  in  practice  that  mineral  acids  before  meals  will  greatly 
benefit  the  patient.  In  some  of  these  gouty  cases,  in  which  many  dif- 
ferent plans  of  treatment  have  entirely  failed,  I  have  found  advantage 
from  giving  mineral  acids  before,  and  a  dose  of  alkali  after,  meals.  You 
will  also  discover,  in  the  course  of  your  practice,  that  half  a  grain  or  a 
grain  of  Calomel,  or  two  grains  or  less  of  Gray  Powder  {Hydrargyrum 
ciim  Creta]  with  three  or  four  grains  of  compound  Colocynth  pill  {Pilula 
Colocynthidis  Composita)  once  or  twice  a  week,  will  be  of  immense 
service  in  many  cases  where  the  liver  is  congested  or  sluggish,  as  well 
as  the  stomach  out  of  order.  The  following  mixture  half  an  hour  after 
breakfast,  lunch,  and  dinner  is  often  of  great  use  to  those  who  have  any 
tendency  to  the  state  of  system  which  precedes  the  development  of  gout. 
Fifteen  or  twenty  minims  of  Liquor  Potasses,  five  grains  of  Nitrate  of 
Potash  (P0/ass<z  Nitras],  ten^minims  of  Tincture  of  Ginger  {Tinctura 
Zingiberis}^  a  drachm  of  Tincture  of  Hop  {Tinctura  Lupnli}  and  one 
ounce  of  water.  There  is,  however,  one  remedy  which  often  succeeds 
in  cases  in  which  other  plans  of  treatment  have  completely  failed.  The 
remedy  to  which  I  refer  is  Pepsine. 

Of  Pepsine  and  its  Uses. — Pepsine  has  been  introduced  into  medi- 
cine for  some  thirty  years  or  more,  but  a  certain  number  of  medical 
advisers  during  every  portion  of  this  time  have  confidently  pronounced 
it  a  worthless  remedy,  and  one  that,  if  it  acts  at  all,  acts  by  pleasing 
the  fancy  of  the  patient.  Not  a  few  have  condemned  it  as  a  ridiculous 
thing  altogether,  as  a  substance  that  has  no  action  whatever  and  does 
not  relieve.  But  if  pepsine  were  really  useless,  like  hundreds  of  other 
things  which  have  been  introduced,  become  fashionable  and  fallen  into 


ITS  PROPERTIES  AND  USES.  103 

disrepute,  it  would  have  been  before  this  time  entirely  discarded,  if  not 
forgotten.  But  what  is  the  fact?  In  spite  of  many  adverse  circum- 
stances, pepsine  is  probably  more  used  than  ever,  and  is  now  made  and 
prescribed  in  every  part  of  the  world.  Many  different  preparations  of 
pepsine  are  sold  to  the  public.  Some  are  extensively  advertised  and 
their  value  extolled  in  superlative  expressions.  Large  sums  of  money 
must  be  annually  devoted  to  the  purchase  of  different  preparations 
stated  tc  be  composed  of  pepsine.  Some  persons  have  no  doubt  found 
out  that  at  least  certain  of  these  preparations  are  of  real  use.  They 
speak  highly  of  them  to  their  friends,  and  thus  the  demand  increases. 
At  this  time  there  is  not  only  a  vast  number  of  different  forms  of 
pepsine  to  be  had,  but  you  may  obtain  the  remedy  in  many  different 
forms.  There  is  pepsine  in  powder,  pepsine  in  pills,  pepsine  in  lozenges, 
pilules  of  pepsine,  pepsine  wine,  and  pepsine  in  glycerine.  It  is  certain 
that  a  great  number  of  people  have  found  it  of  use  to  them.  The 
demand  thus  created  for  a  really  valuable  remedy  has  led  to  the  supply, 
not  only  of  the  real  thing,  but  to  the  production  of  a  number  of 
cheap  and  worthless  substitutes.  Some  preparations  indeed  exist  which 
have  been  proved  to  possess  little  or  no  solvent  action.  He  who 
recommends  pepsine,  or  takes  it,  ought  to  be  quite  sure  that  the  material 
is  really  what  it  purports  to  be.  Although  it  is  very  easy  to  adulterate 
this  substance  or  to  pass  off  something  else  in  its  stead,  it  is  fortunately 
also  very  easy  to  ascertain  whether  the  pepsine  possesses  the  proper 
degree  of  digestive  efficacy.  One  grain  of  good  pepsine  ought  to 
thoroughly  digest  one  hundred  grains  of  boiled  white  of  egg  in  three 
or  four  hours  at  a  temperature  of  100°  F. 

In  order  to  test  the  value  of  any  particular  specimen  of  pepsine  you 
may  proceed  as  follows : — One  hundred  grains  of  hard-boiled  white  of 
egg  cut  into  thin  slices  may  be  placed  in  a  wide-mouthed  bottle  or  flask 
with  one  ounce  of  water,  and  twenty  drops  of  dilute  hydrochloric  acid 
(Acidum  Hydrochloricum  dilutuni).  One  grain  of  pepsine  powder  is  to 
be  added,  and  the  mixture  placed  before  a  fire,  at  a  temperature  of 
about  1 00°  F.  The  flask  is  to  be  shaken  from  time  to  time.  In  about 
an  hour  the  white  of  egg  begins  to  look  transparent  at  the  edges,  and  in 
about  four  hours  it  will  be  completely  dissolved  if  the  pepsine  is  good. 
Pepsine  will  dissolve  white  of  egg  at  ordinary  temperatures  if  a  longer 
time  (from  twelve  to  twenty-four  hours)  be  allowed  for  the  Action. 

Now,  since  less  than  one  single  grain  of  good  pepsine  will  digest  100 
grains  of  white  egg,  two  or  three  grains  ought  to  digest  as  much  meat 
as  would  be  found  in  the  "eye"  of  a  small  mutton-chop.  Three  or 
four  grains,  therefore,  of  good  pepsine  is  a  sufficient  dose,  and  will 
enable  a  patient  to  digest  a  small  meal  of  meat  even  if  the  stomach 
secretes  hardly  any  of  the  active  substance,  but,  as  a  general  rule, 
pepsine  is  only  required  to  set  the  digestive  process  going,  and  probably 


IO4  PREPARATION  OF  PEPSINE. 

much  more  than  the  amount  of  meat  which  an  .invalid  would  require 
would  be  dissolved  by  the  dose  of  pepsine  taken.  You  may  obtain 
different  preparations  of  pepsine  and  ascertain  whether  they  really 
possess  the  power  of  digesting  white  of  egg,  and  you  may  be  sure  that 
those  preparations  which  will  not  artificially  digest  the  albumen  in  the 
flask  will  not  digest  food  in  the  stomach,  and  therefore  ought  not  to  be 
prescribed. 

You  may  not  only  easily  ascertain  whether  the  pepsine  you  purchase 
is  good  or  not,  but  if  you  choose  to  take  a  little  trouble  you  may  make 
your  own  pepsine.  There  is  no  difficulty  or  uncertainty  in  the  process 
if  a  little  care  is  taken.  When  I  held  the  Professorship  of  Physiology 
and  of  General  and  Morbid  Anatomy,  I  used  fo  show  to  the  class,  as 
my  predecessors  had  taught  rne  to  do,  the  action  of  the  gastric  juice 
upon  different  kinds  of  food.  But  we  always  found  it  most  difficult  to 
prepare  a  satisfactory  digestive  solution.  We  used  to  make  an  infusion 
by  soaking  for  a  time  in  tepid  water  pieces  of  the  fourth  or.  true  diges- 
tive stomach  of  the  calf.  A  little  hydrochloric  acid  was  then  added, 
and  the  viscid  mixture  was  strained  through  muslin.  But  it  was  often 
difficult  to  strain  it  properly,  and  at  best  we  had  a  thick  ropy  mass 
which  was  by  no  means  clear  and  transparent,  and  could  not  be  made 
so  by  filtration.  Many  of  the  students  of  those  days  were  sceptical,  and 
probably  concluded  that  I  had  carefully  rounded  off  the  edges  of  the 
albumen  so  as  to  make  it  appear  as  if  digestion  had  commenced,  and 
some  were  not  satisfied  that  the  viscid  opalescent  mixture  really  possessed 
the  solvent  action  I  attributed  to  it.  I  was,  therefore,  induced  to  try 
whether  I  could  not  obtain  a  digestive  solution  as  clear  as  water,  in 
which  every  stage  of  change  occurring  in  substances  placed  in  it  could 
be  watched  from  first  to  last.  In  my  first  attempts  I  followed  the  in- 
structions given  by  scientific  chemists,  and  after  conducting  a  number 
of  complex  chemical  operations,  with  the  invariable  result  of  losing  the 
greater  part  of  the  pepsine  I  was  in  search  of,  from  decomposition  in  the 
chemical  operations  to  which  the  mixture  was  subjected,  and  finding 
that  the  processes  for  isolating  the  pepsine  turned  out  so  very  unfortu- 
nately, I  determined  to  try  to  find  some  new  method  of  getting  a  clear 
solution  possessing  active  digestive  properties.  As  usually  happens, 
after  adopting  somewhat  complicated  plans  of  proceeding,  one  slowly 
comes  to  a^dopt  more  and  more  simple  methods,  and  a£  last  an  efficient 
plan  which  can  be  readily  practised  is  perhaps  discovered. 

I  taught  myself  to  prepare  an  artificial  digestive  fluid  by  a  process  so 
simple  and  obvious  that  one  wonders  no  one  had  employed  it  before, 
though  up  to  the  -time  I  put  it  into  practice,  1856-7,  no  one  seems  to 
have  thought  of  the  process.  While  considering  the  digestive  process 
as  carried  out  in  different  animals,  it  occurred  to  me  that  there  was  one 
domestic  animal  whose  diet  coincided  more  nearly  with  that  of  the 


DIGESTIVE  POWDER.  10$ 

human  race  than  any  other.  The  sheep  and  the  ox  were  evidently  less 
likely  to  .possess  a  potent  digestive  material  adapted  for  dissolving 
albuminous  and  allied  substances  than  the  pig.  There  is,  I  believe,  no 
kind  of  animal  food  that  the  pig  will  not  easily  digest,  and  very  quickly, 
too.  A  pig's  diet  contains  animal  as  well  as  vegetable  matter,  and  I 
need  not  tell  you  of  the  extraordinary  quantity  of  nutritious  substances 
of  all  kinds  that  a  pig  will  consume  and  digest  without  difficulty.  It 
seemed,  therefore,  not  improbable  that  the  best  and  strongest  gastric 
juice  would  be  found  in  the  gastric  glands  of  the  stomach  of  the  pig. 

I  procured  some  fresh  pigs'  stomachs,  and,  after  having  slit  them 
open  and  removed  the  contents,  I  dissected  the  mucous  membrane 
away  from  the  muscular  coat.  This  must  be  done,  because  the  mucous 
membrane  will  be  found  in  the  stomach  of  the  animal  to  be  thrown  up 
into  a  number  of  thick  folds,  and  it  is  required  to  be  laid  out  smoothly 
on  a  flat  board.  When  the  thick  mucous  membrane  is  thus  spread  out, 
a  little  water  is  allowed  to  run  over  it  so  as  to  remove  much  of  the  dirty 
mucus,  and  the  remains  of  the  food, — and  pigs'  food,  as  you  well  know, 
is  not  of  the  nicest  character.  You  have  then  before  you  a  soft,  tolerably 
clean,  smooth  mucous  membrane,  which,  in  its  entire  thickness,  consists 
of  hundreds  of  thousands  of  pepsine-producing  glands.  But  these 
gland-tubes  are  very  minute.  How  are  we  to  get  the  modicum  of 
secretion  which  each  contains?  The  mouths  of  the  little  glands,  as  is  well 
known,  open  on  the  free  surface  of  the  mucous  membrane.  It  occurred 
to  me  that,  if  I  could  only  squeeze  these  glands,  I  might  be  able  to 
press  from  the  tube  the  active  digestive  substance  which  each  contains, 
and  before  any  chemical  change  of  the  nature  of  decomposition  could 
even  have  commenced  in  it.  I  took  a  paper-knife,  and  by  firmly  scraping 
the  surface  in  one  direction,  I  succeeded  in  squeezing  out  the  little 
drops  of  mucus  from  the  gastric  glands,  without  any  difficulty  whatever. 
In  this  way  I  sometimes  obtained  as  much  as  three  or  four  teaspoonfuls 
of  thick  viscid  mucus  from  a  single  stomach.  But  this  substance  is  not 
a  very  manageable  material  for  experiment.  It  will  not  dissolve  in 
water,  though  it  may  be  diffused  through  it.  The  mixture  will  be  very 
viscid,  and  it  will  not  pass  through  filtering  paper,  while  it  very  quickly 
passes  into  a  state  of  decomposition.  Few  things  could  be  less  suitable 
for  delicate  experiments. 

Having  then  obtained  the  potent  material  in  the  active  state  in  which 
it  exists,  as  formed  in  the  body  of  the  animal,  I  thought  that,  in  order  to 
prevent  decomposition,  the  plan  would  be  to  dry  it  as  soon  as  possible. 
I  therefore  spread  the  mucus  in  a  very  thin  layer  over  the  surface  of  a 
piece  of  clean  glass  about  a  foot  square.  The  glass,  with  the  mucus,  was 
next  quickly  dried,  at  a  temperature  of  100°,  before  the  fire,  a  current 
of  air  being  allowed  to  play  freely  over  it.  In  from  twenty  minutes  to 
half  an  hour  the  mucus  became  perfectly  dry,  and  could  then  be  easily 


IO6  ON  MAKING  PEPSINE. 

scraped  off  the  glass.  Being  powdered  in  a  mortar,  it  formed  a  tolerably 
fine  powder,  which  had-  scarcely  any  smell,  but  tasted  a  little  salt.  If  I 
took  a  pinch  of  this  dry  mucus  and  mixed  it  with  a  little  tepid  water,  I 
no  longer  got  a  ropy  mass,  but  a  mixture  which,  by  filtration,  yielded  a  per- 
fectly clear  fluid.  You  may,  indeed,  without  difficulty,  make  a  perfectly 
clear  acid  infusion  of  the  mucus  from  the  pig's  stomach,  by  adding  to 
the  dried  mucus  and  water  a  few  drops  of  dilute  hydrochloric  acid.  You 
will  then  have  a  very  potent  digestive  fluid,  which,  after  standing  for  an 
hour  or  so  with  occasional  stirring,  will  be  found  to  readily  pass  through 
the  pores  of  the  filter.  If  all  the  operations  have  been  successfully  per- 
formed, the  filtrate  will  be  as  clear  as  the  purest  water ;  indeed,  you 
would  not  from  its  appearance  know  it  from  water.  If  you  perform  the 
experiment  with  white  of  egg,  as  described  in  page  103,  and  place  the  flask 
at  a  temperature  of  100°,  you  will  find  that  the  clear  solution  possesses 
active  digestive  properties.  You  may  try  various  experiments,  for  the 
fluid  being  so  clear  you  can  watch  the  changes  which  take  place,  and 
study  the  process  of  digestion  with  facility. 

Having  obtained  this  dried  powder  from  the  mucus  secreted  by  the 
gastric  glands  of  the  pig's  stomach,  and  found  that  such  excellent  arti- 
ficial digestive  fluids  could  be  easily  prepared  with  its  aid,  it  seemed 
desirable  to  try  it  medicinally  as  an  aid  to  digestion,  as  it  was  evidently 
more  efficient  than  many  of  the  preparations  of  pepsine  at  that  time  in 
vogue.  So  I  put  it  to  the  test  in  my  own  body,  and  swallowed  some  of 
the  dried  powder.  It  did  me  no  harm.  Then  I  made  some  into  three 
grain  pills,  and  took  one  before  each  meal  for  several  successive  days. 
Infusions  were  prepared,  which  I  drank,  and  no  inconvenience  whatever 
resulted  from  their  use.  After  a  time  I  prescribed  the  medicine  for 
others,  and  soon  found  that  it  was  really  useful  in  assisting  digestion. 
It  relieved  the  uneasiness  accompanying  the  process  in  many  cases, 
slightly  encouraged  the  action  of  the  bowels,  and  prevented  the  develop- 
ment of  flatus  in  many  instances  in  which  inconvenience  and  suffering 
had  resulted  from  this  circumstance.  Indeed,  there  could  be  no  doubt 
that  this  would  be  a  useful  remedy  in  many  cases  where  the  digestive 
power  of  the  stomach  was  impaired.  Mixed  with  the  food  of  infants, 
the  powder  assists  digestion  in  many  cases,  and  in  old  age  it  is  in- 
valuable. Many  old  people  whose  digestion  is  greatly  impaired  may, 
indeed,  prolong  their  lives  if  the  process  of  digestion  be  assisted  by 
mixing  with  the  food,  or  by  administering  just  before  meals,  a  little  of 
the  powdered  mucus  from  the  pig's  stomach. 

By  careful  microscopic  examination  I  satisfied  myself  that  there 
were  no  substances  in  the  powder  likely  to  do  harm,  and  though  I  have 
examined  the  mucus  from  the  pig's  stomach  in  vdy  many  cases,  I  never 
once  discovered  an  entozoon  of  any  kind,  or  an  ovum  of  an  entozoon. 
When  one  considers  how  quickly  the  epithelial  surface  is  formed,  and 


ITS  MANUFACTURE    ON  A   LARGE  SCALE.  IO? 

cast  off  in  the  discharge  of  function,  one  is  not  surprised  at  this. 
Indeed,  though  of  course  the  possibility  of  such  objectionable  bodies 
being  present  in  the  mucus  occurred  to  me  at  the  outset,  and  has 
doubtless  suggested  itself  to  others,  the  facts  of  the  case  render  it  most 
improbable,  and  any  objections  under  this  head  to  the  method  of  pre- 
paring pepsine  powder  rest  on  no  foundation  in  fact.  I  therefore  had 
no  hesitation  in  taking  and  recommending  the  remedy.  The  next 
thing  to  do  seemed  to  be  to  try  and  get  some  one  to  prepare  this  pep- 
sine  in  quantity,  so  that  the  profession  might  prescribe  it,  and  patients 
have  the  advantage  of  its  use.  I  therefore  spoke  to  Mr.  Bullock,  of 
the  firm  of  Bullock  and  Co.,  whom  I  had  known  for  many  years  as  a 
scientific  chemist  of  the  highest  character,  and  begged  him  to  try  my 
plan  of  preparation,  and  see  if  he  could  arrange  for  a  sufficient  supply 
of  pigs'  stomachs  to  make  the  powder  in  quantity.  This  was  more 
than  twenty-five  years  ago,  and  the  remedy  is  now  made  in  large 
amounts  both  here  and  in  America,  and  it  is  used  in  every  part  of  the 
world.  The  process  I  adopted  for  making  it  was  described  in  the  first 
volume  of  the  "Archives  of  Medicine,"  page  269.  Mr.  Bullock  has, 
I  believe,  made  some  improvements  in  the-  details  of  the  process  of 
preparing  the  material,  and  by  great  care  and  rapid  drying  at  a  low 
temperature  the  proper  degree  of  activity  of  the  solvent  matter  has  been 
insured,  and  maintained  at  a  given  standard  in  every  specimen  that  is 
made.  Any  of  you  can  test  the  action  of  the  Pepsina  Porci  in  the 
simple  manner  I  have  described  in  page  103.  You  will  find  that  a 
single  grain,  in  point  of  fact  8-ioths  of  a  grain,  will  completely  digest 
one  hundred  grains  of  the  white  of  egg.  It  is  interesting  to  watch,  in 
a  common  bottle  before  an  ordinary  fire,  the  opaque  albumen  becoming 
gradually  translucent,  and  then  the  transparent  albumen  gradually 
breaking  down  until  a  complete  solution,  a  peptone,  is  formed.  In  this 
way  you  may  get  what  is  known  as  albumen  peptone.* 

Mr.  J.  R.  James,  of  the  firm  of  Bullock  and  Co.,  has  lately  been 
studying  the  properties  of  the  so-called  "Ostrich  Pepsine"  ("Pharma- 
ceutical Journal,"  February  2oth,  1880).  This  substance,  of  which 

*  The  only  objection  made  to  the  process  I  have  recommended  is  the  very  strange 
one,  urged  by  Mr.  Squire,  who  remarks  that  the  pepsine  made  according  to  the  plan 
above  described  contains  epithelium,  and  that  if  exposed  to  a  damp  atmosphere  "  it 
becomes  putrid  more  or  less,  and  acquires  a  most  repulsive  odor."  But  who  would 
think  of  placing  pepsine  or  other  organic  substances  of  any  kind  in  a  damp  atmos- 
phere? Does  Mr.  Squire  mean  to  suggest  that  the  pepsine  made  by  him,  or  any 
pepsine  in  the  world,  will  not.  putrefy  and  acquire  a  most  repulsive  odor  if  placed  in  a 
damp  atmosphere  ?  The  substance  that  does  not  change  under  these  circumstances 
cannot  be  pepsine.  I  regret  to  have  to  comment  upon  such  criticisms  as  the 
above.  The  test  of  pepsine  is,  of  course,  its  solvent  power,  and  the  dried  mucus  of 
the  pig's  stomach  is  in  this  respect  so  potent  that  8-ioths  of  a  grain  will  dissolve  100 
grains  of  coagulated  albumen. 


108  PEPSIN E    OF    VARIOUS  KINDS. 

there  is  a  specimen  in  the  Museum  of  the  Pharmaceutical  Society,  is 
thus  described  ("Medical  Times  and  Gazette")  by  M.  Ebelot : — 
"  The  stomach  of  the  ostrich  is  celebrated  for  its  incredible  power  of 
digestion.  The  abundance  of  pepsine,  to  which  it  owes  this  faculty,  has 
created  among  the  Indians  a  curious  commercial  fraud.  They  dry  it, 
and  sell  it  literally  for  its  weight  in  gold.  It  is  used  for  the  purpose  of 
restoring  worn-out  stomachs."  A  correspondent  to  the  "Pharmaceu- 
tical Journal"  says: — "In  the  Argentine  Republic,  ostrich  pepsine  is 
prescribed  by  medical  men,  and  known  by  the  public  as  '  pepsina 
nostra.'  A  good  wine  is  made  by  digesting  the  stomachs  in  wine.  I 
consider  this  a  useful  article ;  but  being  a  rough  preparation  our  pepsine 
is  preferable." 

Beyond  these  loose  statements  no  experimental  results  have  been 
published,  so  far  as  I  know.  A  fair  and  impartial  trial  should,  of 
course,  be  given  to  this  substance  by  those  who  have  the  means  at  their 
disposal  of  testing  it,  but  care  must  be  taken  that  a  worthless  prepara- 
tion should  not  receive  credit  for  performing  a  service  which  it  is  in- 
capable of  rendering. 

Mr.  James  says: — "  Whilst  conducting  my  experiments  upon  ostrich 
pepsine  my  attention  was  drawn  to  another  preparation,  called  '  In- 
gluvin,'  thus  described  in  the  'Medical  Times  and  Gazette'  for 
May  10,  1879  :  'This  is  a  new  remedy,  prepared  by  Warner  and  Co. 
from  the  ventriculus  callosus  gallinaceus.  It  is  said  to  be  superior  to 
pepsine  as  a  remedy  for  feeble,  painful,  and  imperfect  digestion,  and 
may  be  prescribed  in  the  same  manner,  dose,  and  combinations.  .  .  . 
Ingluvin  prepared  from  the  gizzard  of  the  chicken  is  the  nearest 
approach  to  ostrich  pepsine  that  can  be  obtained  in  Europe,  we  sup- 
pose.' Naturally,  I  felt  a  little  curious  to  test  this  preparation,  and 
applied  for  some  to  the  agents,  who  most  readily  supplied  me.  Below 
I  have  tabulated  the  results  obtained. 

"Fresh  eggs  were  kept  in  boiling  water  for  one  hour,  and  then 
allowed  to  get  quite  cold  ;  after  depriving  them  of  their  shells  the 
whites  were  cut  into  the  thinnest  possible  slices — not  minced,  as  it  is 
easier  to  observe  the  progress  of  the  digestion  of  albumen  if  it  be 
sliced  than  if  it  be  minced — and  care  was  taken  to  reject  any  portion  of 
yolk.  Fifty  grains  of  coagulated  albumen  thus  prepared  were  placed  in 
each  wide-mouthed  bottle  and  covered  with  five  drachms  of  distilled 
water,  containing  i  per  cent,  of  hydrochloric  acid,  specific  gravity  i'i6. 
The  quantity  of  pepsine  was  then  weighed  out  and  added  to  the  mixture 
of  albumen  and  dilute  hydrochloric  acid.  The  bottles  and  their  con- 
tents were  then  placed  in  a  water-bath  and  kept  at  a  temperature  of 
98°  to  102°  F.  for  four  hours,  when  digestion  was  regarded  as  com- 
plete. « 


PEPSINE    OF  OSTRICH  AND  OTHER  BIRDS.  TOp 

Kind  of  pepsine  Weight  of  pepsine 

employed.  employed. 

Pig  Pepsine  .........       \  grain  .........  Digested. 

Ostrich  Pepsine  ...     z\  grains    ......  Not  Digested. 

tt  It  £-  It  tl 

ft  (I  JQ  tl  It 

Ingluvin  .............     2j      "        ......  " 


"         .............   10       "        ......  " 

"  From  the  results  detailed  in  the  foregoing  table,  and  illustrated  in 
the  bottles-shown,  it  will  be  seen  that  the  albumen  is  scarcely  acted  upon 
at  all,  and  thai  both  ostrich  pepsine  and  ingluvin  are  destitute  of  the 
power  of  digestion.'11  Much  larger  quantities  of  "Ostrich  pepsine" 
and  "Ingluvin"  might  have  been  taken  with  probably  no  difference 
in  results. 

"  In  the  stomach  of  the  river  crayfish  is  found  a  plentiful  supply  of 
a  yellowish-brown,  feebly  acid  juice,  which  possesses  an  energetic,  fer- 
menting power,  and  rapidly  dissolves  fibrin,  but  the  addition  of  a  few 
drops  of  a  dilute  hydrochloric  acid  solution  stops  the  action.  Also,  a 
somewhat  similar  ferment  to  pepsine,  discovered  by  Fick  and  Murisier, 
in  the  stomachs  of  frogs,  pikes,  and  trout,  differs  from  it  (pepsine)  in 
being  more  active  at  a  low  temperature,  as  at  20°  F.,  while  it  loses  its 
digestive  power  at  the  temperature  of  the  blood  (96°  to  98°  F.)." 

Besides  indigestion  and  weak  digestion,  there  is  another  class  of 
cases  in  which  pepsine  is  of  the  greatest  service,  in  which  you  must  not 
neglect  to  employ  it.  In  fever  the  action  of  the  stomach  is  more  or 
less  disturbed.  Indeed,  in  all  fevers  the  process  of  digestion  seems  to 
be  greatly  deranged.  When  the  feverish  state  is  induced  in  one's  own 
organism,  one  of  the  first  points  noticed  is  loss  of  appetite.  The 
feverish  patient  does  not  feel  the  ordinary  desire  for  food.  When  meal- 
time arrives,  he  is  disinclined  to  eat.  If,  therefore,  you  find  a  patient 
who,  perhaps,  has  been  suffering  from  fever  for  many  weeks,  especially  if 
emaciation  is  extreme,  and  the  strength  almost  exhausted,  it  will  be  well 
to  adopt  the  practice  I  have  long  acted  upon,  and  add  pepsine  to  the 
milk  and  beef-tea  in  the  proportion  of  three  or  four  grains  to  a  pint. 
Milk  will  be  coagulated  at  first,  but  soon  afterwards  it  will  become 
partially  digested,  and  the  curd  maybe  easily  broken  up  into  very  small 
pieces.  Both  the  whey  and  curd  will  be  in  a  state  favorable  for 
digestion,  and  for  being  rapidly  absorbed  and  appropriated  by  the 
bioplasm  or  living  matter  of  the  tissues  and  organs. 

If  the  feverish  attack  is  of  a  kind  which  may  continue  severe  for  a 

considerable  period  of  time,  the  body  may  lose  very  much  in  weight, 

the  patient  becoming  excessively  weak,  and  his  life,  perhaps,  for  some 

time  in  jeopardy.     Under  such  circumstances  it  is  of  the  first  import- 

10 


I IO  ON  FEEDING  BAD  CASES  OF  FE  VER. 

ance  to  support  the  strength  to  the  utmost.  By  mixing  a  little  pepsine 
with  the  food  you  will  greatly  assist  the  digestive  process.  It  may  be 
during  a  most  critical  period  of  the  malady,  that  the  nutriment  is  given 
in  the  form  of  a  peptone,  and  in  a  state  fit  to  be  immediately  taken  up 
by  the  vessels,  and  converted  into  blood  constituents,  and  thus  by  this 
expedient  life  may  be  actually  saved.  I  have  lately  (1878)  had  under 
my  care  a  poor  girl  who  became  excessively  emaciated  in  a  prolonged 
attack  of  typhoid,  the  temperature  varying  from  102°  to  105°  during  a 
period  of  six  weeks.  About  the  first  week  distention  of  the  stomach 
and  bowels  by  gas  became  considerable,  and  added  much  to  the  distress. 
I  gave  six  grains  of  pepsine  daily,  with  a  little  hydrochloric  acid  in  the 
beef-tea,  and  kept  this  up  during  the  whole  period  of  the  illness.  The 
distention  diminished  after  a  few  days,  and  I  think  that  this  simple  plan 
had  much  to  do  with  recovery  in  this  instance.  In  the  case  of  beef-tea 
you  may  with  advantage  add  a  little  hydrochloric  acid,  and  place  the 
mixture  before  the  fire  at  a  temperature  of  100°,  for  an  hour  or  two 
before  the  patient  takes  it.  He  will  not  dislike  it,  and  to  some  the  acid 
beef-tea  seems  even  pleasant.  But  generally  when  patients  are  as  ill 
from  fever  as  I  am  supposing,  the  taste  is  very  much  impaired,  and 
practically  there  is  no  difficulty  in  getting  persons  to  swallow  the  easily 
digestible  peptones  in  the  form  of  beef-tea.  Peptonized  fluid  meat  was 
first  made  in  quantity  some  years  ago  by  Mr.  Darby.  This  useful  pre- 
paration may  now  be  obtained  ready  for  use,  in  small  pots  or  bottles  in 
a  form  in  which  it  will  keep  good  for  some  time,  of  Messrs.  Savory  and 
Moore,  143,  New  Bond  Street,  London.  Do  not,  therefore,  forget  this 
hint  as  regards  the  treatment  of  very  bad  cases  of  fever,  and  of  pro- 
longed exhausting  disease.  Whenever  too  little  nutriment  is  absorbed 
for  the  support  of  the  patient  in  consequence  of  the  imperfect  action 
of  the  stomach,  the  remedy  will  be  useful,  and  now  and  then  I  have  no 
doubt  a  life  may  be  saved  by  the  practice  I  have  described. 

Another  plan  based  on  the  same  principle  maybe  adopted.  Instead 
of  giving  strong  beef-tea  or  soup  containing  pepsine,  you  may  make  a 
Sort  of  meat  jam.  Underdone  or  perfectly  raw  mutton  or  tender  beef 
may  be  cut  up  into  small  pieces,  put  into  a  mortar  and  well  beaten  with 
the  pestle  until  it  forms  a  soft  pulpy  mass.  A  small  quantity  of  salt 
may  be  added  to  make  it  palatable.  Pepsine  in  the  proportion  of  ten 
grains  of  the  powder  to  an  ounce  of  meat  is  then  to  be  beaten  up  with 
it,  when  a  drachm  or  more  of  dilute  hydrochloric  acid  is  to  be  poured 
in,  and  the  whole  thoroughly  mixed  together.  If  you  choose  you  may 
further  add  a  little  sugar  instead  of  salt  to  the  mass.  This  panada  or 
paste  may  be  spread  upon  bread  and  butter,  or  it  may  be  diffused 
through  beef-tea  or  soup.  Children,  and  many  invalids,  will  often  take 
a  compound  of  this  sort  when  it  is  difficult  to  persuade  them  to  take 
ordinary  meat  food  at  all. 


OF  CONSTIPATION.  Ill 

In  some  cases  of  illness  we  are  unable  to  feed  the  patient  by  the 
mouth,  and  in  fevers  it  sometimes  happens  that  everything  that  touches 
the  mucous  membrane  of  the  stomach  immediately  excites  the  most 
violent  vomiting,  and  occasionally  this  state  lasts  for  so  long  a  time  that 
there  is  danger  of  the  patient  perishing  from  inanition.  In  these,  as 
well  as  in  those  bad  cases  where  there  is  a  physical  impediment  to  the 
entrance  of  food  into  the  stomach,  or  to  its  escape  from  the  organ  into 
the  duodenum,  we  may  keep  the  patient  alive  for  many  months  by 
injecting  nutrient  substances  in  small  quantities  (an  ounce  to  three  or 
four  ounces)  at  a  time  into  the  lower  part  of  the  bowel.  The  nutritious 
matter  dissolved,  or  suspended  in  some  mucilaginous  substance  like 
boiled  starch,  is  introduced  into  a  small  elastic  syringe  made  for  the 
purpose,  and  slowly  injected  into  the  rectum,  the  operation  being 
repeated  every  three  or  four  hours.  To  the  beef-tea  employed  for 
this  purpose  it  is  well  to  add  two  grains  of  pepsine  to  the  ounce.  The 
rate  of  its  absorption  is  increased,  and  it  is  more  easily  assimilated  and 
taken  up  by  the  vessels  of  the  mucous  membrane. 

You  will  find  in  the  memoirs  of  Dr.  W.  Roberts,  published  in  the 
"Transactions"  and  "Proceedings  of  the  Royal  Society,"  and  in  his 
Lectures  at  the  Royal  College  of  Physicians,  many  new  points  in  con- 
nection with  the  question  of  the  action  of  the  gastric  juice,  pancreatic, 
and  other  secretions  concerned  in  stomach  and  intestinal  digestion,  as 
well  as  instructions  for  applying  the  principles  deduced  from  scientific 
investigation  to  the  treatment  of  disease. 

OF  CONSTIPATION. 

We  must  now  consider  a  very  important  and  almost  universal 
accompaniment  of  the  most  common  forms  of  deranged  digestion  and 
indigestion,  and  of  which  the  majority  of  persons  at  some  time  or  other 
have  to  complain.  Constipation,  a  condition  which  varies  greatly  in 
degree,  would,  perhaps,  be  more  correctly  described  as  imperfect  or 
insufficient  action  of  the  bowels.  Probably  nearly  every  one  of  us  has 
suffered  more  or  less  from  this  trouble.  And  those  who  are  accustomed 
to  sedentary  pursuits  and  intellectual  work  have  usually  a  more  extended 
experience  of  sluggish  action  of  the  bowels  than  those  who  take  a  good 
deal  of  exercise,  and  those  who  have  to  live  by  bodily  labor.  But  I 
suppose  there  is  hardly  one  who  follows  any  walk  of  life  whatever,  or 
who  follows  no  walk  at  all,  who  has  entirely  escaped  this  derangement. 
The  most  idle,  as  well  as  the  most  industrious,  often  have  to  complain 
of  constipation,  and  the  condition  may  afflict  people  of  all  ages  and  of  all 
classes  and  in  all  climates.  It  is  probably  one  of  the  most  common  of 
the  slight  derangements  to  which  civilized  man  is  subject.  Whether 
savages  suffer  from  it  I  do  not  know,  but  unquestionably  the  majority 
of  persons  forming  a  civilized  community  experience  the  discomfort. 


112  .OF  CONSTIPATION. 

The  word  "constipation  "  comes  from  the  Latin  "constipare,  to  crowd 
together."  Generally  speaking,  people  attribute  constipation  to  the 
accumulation  of  faeces  in  the  large  bowel,  and  infer,  that  it  is  invariably 
to  be  relieved  by  purgatives.  But  you  will  see,  as  I  go  on,  that  in  cases 
of  constipation  a  number  of  points  have  to  be  considered,  and  that 
many  cases,  so  far  from  being  relieved  by  the  frequent  administration  of 
purgatives,  are  aggravated  by  that  proceeding. 

Most  persons  empty  the  lower  part  of  the  large  intestine,  or  at  any 
rate  partially  empty  it,  once  during  each  period  of  twenty-four  hours. 
But  some  persons'  bowels  have  a  habit  of  not  being  relieved  oftener 
than  every  other  day ;  some  have  an  evacuation  once  in  two  or  three  or 
four  days,  and  a  few  females  maintain  that  once  a  week  is  enough  to 
empty  their  bowels.  Nay,  I  have  heard  it  asserted  that  an  action  once 
in  a  fortnight  was  sufficient,  and  I  am  bound  to  admit  that  there  are 
instances  in  which  habitual  constipation  is  not  associated  with  derange- 
ment of  the  health,  although,  as  a  general  rule,  this  sluggish  state  of  the 
bowels  brings  about  general  disturbance  of  the  health,  and  sometimes 
leads  to  very  distressing  results.  Of  course,  in  cases  in  which  faecal 
accumulation  goes  on  for  many  days,  the  lower  part  of  the  large  bowel 
gradually  attains  enormous  dimensions,  and  considerable  increase  in  its 
capacity  and  stretching  of  its  walls  must  ensue  before  it  is  sufficiently 
large  to  hold  the  excrementitious  matter  formed,  as  well  as  all  the  refuse 
material  of  the  food  which  accumulates  during  the  considerable  periods 
of  time  just  mentioned.  I  need  scarcely  say  that  this  is  a  very  unsatis- 
factory state  of  things,  and  if  allowed  to  persist  for  years,  is  likely  to 
lead  to  disastrous  consequences  as  age  advances.  There  is  no  doubt, 
that  if  the  large  bowel,  and  indeed  the  intestinal  canal  generally,  is  to 
retain  its  healthy  state,  and  to  be  preserved  in  good  working  order  for 
sixty  or  seventy  years,  or  more,  its  contents  ought  to  be  expelled,  as  I 
have  before  stated,  once  in  every  period  of  twenty-four  hours. 

Many  of  the  physiological  processes  of  the  body,  like  this  one, 
occur  periodically  and  uniformly  at  about  the  same  time  during  each 
period  of  twenty-four  hours.  Regularity  as  regards  time  much  assists 
the  daily  evacuation  of  the  bowels,  and  it  is  very  desirable  that  every 
one  should  do  all  he  can  to  acquire  the  habit.  I  do  not  think  it  matters 
much  whether  the  bowels  act  the  first  thing  in  the  morning,  after  break- 
fast, or  the  last  thing  at  night,  so  that  the  habit  is  acquired  and  a  fixed 
time  kept.  Even  in  the  case  of  animals,  at  least  domestic  ones,  this 
operation  is  usually  performed  with  the  greatest  regularity  at  a  particular 
hour.  If  you  have  a  pet  cat  or  dog,  you  will  find  it  convenient  to  teach 
it  to  evacuate  its  bowels  at  a  given  time,  and  it  will  prove  more  than 
inconvenient  if  the  creature  should  be  unteachable  in  this  respect.  An 
unmanageable  disposition,  or  disobedience  in  this  respect,  renders  an 
otherwise  valuable  animal  almost  worthless. 


COMPLETE  EMPTYING    OF  BOWELS.  113 

You  must  impress  upon  all  patients  the  importance  of  regular 
habits,  which  are,  in  fact,  easily  acquired,  and  ought  never  to  be  broken 
through.  Many  small  ailments  and  troubles  of  various  kinds  will  almost 
certainly  result  from  carelessness  in  this  particular,  and  serious  maladies 
are  not  unfrequently  the  consequence  of  disregarding  advice. 

Having  referred  to  the  desirability  of  regular  action,  I  must  now  try 
to  impress  upon  you  the  equal  importance  of  complete,  or  nearly  com- 
plete, evacuation  of  the  lower  part  of  the  large  bowel,  for  what  is  called 
regular  action  may  be  associated  with  very  imperfect  removal  of  the 
contents.  Although  a  small  quantity  of  faecal  matter  is  daily  discharged, 
this  bears  so  small  a  proportion  to  the  quantity  formed,  that  there  is  a 
constantly  increasing  residue,  which  goes  on  accumulating,  to  the  great 
discomfort  of  the  patient,  and  the  derangement  of  his  health.  In  not  a 
few  cases  this  is  no  doubt  due  to  the  weak  muscular  contraction  and 
imperfect  action  of  the  parts  above,  so  that  too  small  a  quantity  is  sent 
down  to  the  rectum  to  excite  that  part  of  the  tube  to  sufficiently  vigorous 
contractile  action.  As  regards  efficient  action,  a  good  deal  usually 
depends  upon  the  rectal  contents.  If  a  person  lives  upon  highly  nu- 
tritious diet,  such  as  very  strong  soup  or  potted  meat,  he  may  find  that 
his  bowels  will  soon  get  obstinately  constipated.  If  now  he  adds  to  this 
highly  nutritive  diet  a  quantity  of  amylaceous  and  soft  fibro-cellular 
vegetable  matter,  which  in  itself  possesses  very  little  nutritive  value,  and 
of  which  comparatively  little  may  be  absorbed,  he  will  find  that  the  bulk 
of  excrementitious  material  will  be  augmented,  and  the  action  of  the 
bowels  will  become  more  satisfactory.  In  fact,  if  we  are  to  be  in  good 
health,  we  have  to  take  a  certain  quantity  of  material  with  the  food 
which  is  not  in  any  way  of  use  to  the  nutritive  operations.  The  propor- 
tion of  nutriment  in  bread  and  potatoes  is  small  as  compared  with  that 
existing  in  fat  meat.  To  obtain  an  equal  amount  of  nutritious  matter, 
a  comparatively  large  quantity  of  bread  must  be  taken,  and  of  potatoes 
many  pounds  daily  must  be  swallowed,  if  this  is  the  only  article  of  diet. 
Up  to  a  certain  point  the  admixture  with  the  really  nutritive  materials  of 
a  large  amount  of  innutritions  dross  is  advantageous,  and  even  in  the 
case  of  vegetable  feeders  this  matter  has  to  be  considered.  A  horse  does 
not  do  so  well  upon  pure  corn  as  upon  corn  and  hay.  Chaff  is  of  far 
more  value  than  you  would  be  led  to  suppose  from  its  chemical  con- 
stituents. Many  of  us  indeed  require  a  certain  amount  of  chaff  to  keep 
ourselves  in  fair  health.  Brown  bread  is  very  dear,  because  it  contains 
so  much  valueless  material,  and  is  a  rougher  kind  of  bread  than  white 
bread.  If  you  examine  brown  bread,  you  will  find  that  it  contains  a 
large  percentage  of  the  testa  of  the  wheat,  which  is  quite  indigestible. 
Oatmeal  is  useful  in  the  same  way.  All  these  things  help  to  increase  the 
bulk  of  the  evacuation,  and  in  this  respect  are  of  great  use  and  do  good. 
Unless  there  is  a  certain  bulk  to  excite  the  fine  nerve  network  of 
10*  H 


114  CRAFTSMEN  SUBJECT  TO   CONSTIPATION. 

the  mucous  membrane  of  the  intestine,  the  reflex  action  upon  which 
the  expelling  action  of  the  muscular  fibres  entirely  depends,  is  not 
brought  about,  or  is  only  very  feebly  and  inadequately  performed. 

Lastly,  the  action  may  be  perfectly  regular,  and  the  contractile 
powers  of  the  bowels  sufficient  to  expel  the  contents,  but,  owing  to  the 
formation  of  a  very  insufficient  quantity  of  excrementitious  matter,  the 
bowel  is  seldom  excited  to  act,  and  the  patient  suffers  perhaps  through  the 
greater  part  of  his  lifewith  the  most  troublesome  form  of  "constipation." 
If  the  formation  of  faecal  matter  is  insufficient,  many  of  the  most  im- 
portant functions  of  the  organism  get  out  of  order.  You  will  find  that 
people  who  suffer  from  this  condition,  though  they  may  have  a  regular, 
but  quantitatively  deficient  action,  complain  of  certain  unpleasant  sen- 
sations. There  is  no  organic  disease.  Indeed,  if  you  examined  every 
part  of  such  person  you  would  not  find  the  least  indication  of  the  slight- 
est structural  change.  Nevertheless,  the  almost  constant  discomfort 
many  of  these  people  have  to  endure  is  really  great ;  and  not  only  so, 
but  various  more  or  less  serious  conditions  may  result  from  this  state  of 
things.  It  is  in  this  way  that  unpleasant  condition  known  as  Hypo- 
chondriasis  in  the  male,  and  as  a  form  of  Hysteria  in  the  female,  very 
often  commences.  There  is  even  the  possibility  that  a  condition  of 
disease  bordering  upon  insanity  may  be  brought  about  by  long-continued 
defective  formation  of  fseces  and  improper  action  of  the  bowels.  Patients 
will  often  come  to  you  complaining  of  very  great  discomfort.  They  tell 
you  they  feel  more  or  less  oppressed,  and  heavy  and  overwhelmed. 
Some  complain  of  an  unpleasant  sensation  all  over  the  surface  of  the 
abdomen.  Instead  of  the  food  which  they  have  taken  gradually  dis- 
appearing, it  seems  as  if  it  went  on  accumulating  and  distending  the 
stomach ;  the  patient  is  blown  up  with  wind,  and  the  distress  is  great. 
Many  persons  who  surfer  in  this  way  soon  lose  their  healthy  complexion 
and  become  more  or  less  sallow  and  pasty.  Indeed,  it  is  quite  extraor- 
dinary how  many  different  derangements  of  the  health  may  result  from 
imperfect  action  or  a  torpid  state  of  the  secreting  and  expelling  struc- 
tures of  the  large  bowel.  There  may  be  violent  and  persistent  nerve 
pains  referred  to  the  back,  or  hip,  or  groin,  and  certain  other  symptoms 
which  lead  pessimist  practitioners  excelling  in  the  discovery  of  neuroses 
to  diagnose  structural  changes  in  some  part  of  the  spinal  cord,  or  the 
antecedent  state  which  is  supposed  to  lead  to  them.  Certain  remediable 
fortns  of  Sciatica  are  undoubtedly  due  to  this  cause,  and  violent  lumbar 
pain  is  also  not  unfrequently  occasioned  by  imperfect  action  of  the 
excreting  functions  of  the  lower  part  of  the  alimentary  canal. 

There  are  many  craftsmen  peculiarly  subject  to  constipation  ;  shoe- 
makers and  tailors,  for  example,  surfer  greatly.  Undoubtedly  many  of 
them  live  to  get  old,  and  most  of  them  are  extremely  intelligent,  thought- 
ful people,  but,  nevertheless,  they  do  not  pay  attention  to  the  action  of 


THE   CONSTIPATION  OF  LITERARY  PERSONS.  11$ 

the  colon.  Literary  men,  teachers,  male  and  female,  professional  men 
generally,  who  take  little  exercise,  more  especially  if  they  live  and  work 
in  small,  badly-ventilated  rooms,  are  great  sufferers.  You  seldom  see  a 
shoemaker  or  a  tailor  with  a  good  color;  and  the  same  remark  applies 
to  many  more  whose  habits  are  too  sedentary.  Nevertheless,  it  will  be 
remarked  that  pasty,  sallow  complexions  often  characterize  men  having 
high  mental  endowments.  Shoemakers  are  renowned  for  intelligence, 
energy,  patience,  endurance,  and  cogitative  power.  Organisms  of  this 
class,  moreover,  frequently  have  great  resisting  capacity,  and  often  live 
to  be  old.  Many  are  excellent  lives  to  insure.  Such  persons  may  suffer 
much,  and,  in  consequence,  are  often  neither  happy  nor  contented. 
They  are,  perhaps,  very  despondent  or  excessively  irritable,  and  are  not 
always  very  pleasant  companions.  Some  of  them  who  are  so  unfortu- 
nate as  not  to  have  to  work  for  their  living,  spend  too  much  time  in 
thinking  of  themselves,  their  aches,  and  pains.  Sufferers  often  complain 
of  slight  nausea,  and  of  some  discomfort  about  the  stomach,  with  a 
sense  of  fulness  of  the  head.  -An  indescribable  feeling  of  depression  is 
sometimes  described  as  being  so  severe  as  to  render  the  patient  almost 
unable  to  control  his  actions.  Persons  who  suffer  from  constipation  get 
very  tired  after  slight  exertion,  or  feel  tired  without  having  exerted 
themselves  at  all.  They  tell  you  they  are  unable  to  walk ;  or,  if  they 
walk  a  little  way,  they  get  so  tired  and  exhausted  that  they  are  obliged 
to  come  back  and  lie  down.  Very  commonly,  as  I  have  mentioned,  there 
is  uneasiness,  and  not  unfrequently  actual  pain.  Almost  invariably  in 
this  disorder  there  is  a  feeling  of  lassitude,  an  indescribable  malaise,  a 
disinclination  to  exertion  of  every  kind,  and  frequently  the  patient  is 
discontented  with  the  position  in  which  he  happens  to  be  placed,  though 
the  discontent  is  shown  rather  by  frequent  grumbling  than  by  any  active 
attempts  to  change  his  surroundings.  He  does  not  make  any  effort  to 
place  himself  elsewhere,  in  order  that  he  may  be  better  pleased  and 
happier.  The  only  way  to  help  such  people  is  to  allow  them  to  growl, 
and  then  try  to  persuade  them  to  take  steps  to  relieve  the  troubles  from 
which  they  suffer,  and  in  this  effort  you  will  generally  meet  with  at  least 
partial  success.  They  perhaps  find  fault  with  you  and  with  everybody 
about  them.  You  may  meet  with  individuals  belonging  to  this  class 
who  seem  inclined  to  pick  small  quarrels  with  almost  any  one,  and  can- 
not, or  will  not,  control  their  discontent.  Successful  critics  are  often  of 
this  disposition,  and  many  a  severe  article  would  never  have  seen  the 
light  if  the  glands  of  the  critic's  large  bowel  had  been  in  good  order  at 
the  time.  This  troublesome  ailment  then  has  its  advantages.  It  brings 
profit  to  editors,  proprietors,  and  that  important  section  of  a  civilized 
community  which  delights  in  finding  fault,  and  flourishes  according  to 
the  skill  it  displays  in  reviling.  Any  of  you  who  desire  to  excel  in  this 
department  of  literature  cannot  do  better  than  cultivate  indigestion  and 


1 1 6  IMP  A  CTION .  OF  FAECAL   MA  TTER. 

imperfect  action  of  the  bowels,  and  a  condition  to  which  I  shall  pre- 
sently have  to  refer,  under  the  head  of  biliousness.  A  constipated, 
bilious  dyspeptic  is  the  sort  of  person  soon  to  become  a  first-class  critic, 
and  his  articles  will  command  high  remuneration,  and  be  read  by  every 
one  who  is  dissatisfied  with  his  environment. 

Constipation  with  Impaction  of  Facal  Matter  in  the  Large  In- 
testine.— As  the  tissues  get  old  their  action  becomes  less  vigorous,  and 
the  nerves  respond  more  and  more  slowly  and  less  readily  to  their 
wonted  stimulus.  The  muscular  fibres  of  the  bowel  become  weak  and 
lose  much  of  their  contractile  power.  Particularly  the  muscular  tissue 
of  the  large  intestine,  like  that  of  the  bladder,  becomes  more  or  less 
feeble,  and  the  viscus  is  unable  to  expel  its  contents.  The  collection 
of  faeces  therein  may  give  rise  to  serious  trouble.  In  old  age  some 
artificial  stimulus  is  required  from  time  to  time  to  excite  the  weakened 
muscular  fibres  to  contract  with  sufficient  vigor  to  cause  the  bowel  to 
empty  itself.  In  old  age  faecal  matter  often  goes  on  accumulating  for 
a  long  period  of  time.  The  collection  is  so  gradual  that  the  patient 
may  not  be  conscious  of  it.  By  putting  your  hand  over  the  belly,  and 
particularly  over  those  parts  in  which  the  large  bowel  is  situated,  you 
may  often  feel  the  colon  for  a  considerable  portion  of  its  extent  much 
distended  by  an  accumulation  of  hard  faecal  matter.  At  the  same  time 
you  may  ascertain  whether  there  is  also  wind  in  the  large  bowel.  If 
you  place  one  or  two  fingers  of  the  left  hand  over  the  surface  and  strike 
the  back  of  one  finger  sharply  with  the  tip  of  the  finger  of  the  right 
hand,  you  will  be  able  to  decide  at  once  according  to  the  note  elicited 
by  percussion.  A  dull  sound  -indicates  solid  matter,  while  a  hollow, 
drum-like  note  (tympanitic)  indicates  air  in  the  bowel  beneath. 

Constipation  has  caused  death.  I  recollect  seeing  an  old  lady  who 
had  been  bedridden  for  years,  and  was  in  fact  dying  when  she  came 
under  my  observation,  whose  abdomen  had  increased  to  an  enormous 
size.  To  my  great  astonishment,  when  I  came  to  examine  it,  I  found 
the  swelling  due  to  an  enormous  accumulation  of  hard  faecal  matter. 
There  was  no  fluid,  and  very  little  gas ;  but  the  whole  abdomen 
seemed  occupied  by  a  huge  mass  of  hardened  faeces — I  should  think 
amounting  in  weight  to  30  or  40  pounds.  Unfortunately,  I  only  saw 
the  patient  a  few  hours  before  death,  when  she  was  reduced  to  the  last 
state  of  exhaustion,  and  when  it  was  impossible  to  interfere.  In  this 
case  faeces  had  probably  been  gradually  accumulating  in  the  intestines 
without  attracting  notice.  The  patient  being  bedridden,  the  circum- 
stance seems  to  have  escaped  observation.  Probably,  if  a  medical 
practitioner  had  been  allowed  to  interfere  some  six  months  before,  the 
patient  might  have  been  saved.  Injections  might  have  been  given,  and 
the  contents  of  the  bowel  thus  removed  before  any  harm  to  it  had 
resulted. 


REABSORPTION  OF  FLUID  FROM  INTESTINE.  1 1/ 

Influence  of  the  Reabsorption  of  Fluid  by  the  Intestinal  Surface  in 
causing  Constipation. — In  many  cases  of  constipation  you  find  that  the 
faecal  matter  is  too  dry  to  pass  freely  along  its  wonted  channel.  It 
would  seem  that  in  many  persons  there  is  too  rapid  absorption  of  fluid 
by  the  intestinal  surface.  If  the  vessels  of  the  large  intestine  take  up 
too  much  of  the  fluid  which  is  associated  with  the  faecal  matter,  the 
bulk  may  be  so  much  reduced  that  the  peristaltic  action  of  the  bowels 
is  not  so  readily  excited,  and  it  may  be  insufficient  to  drive  on  the  con- 
tents fast  enough.  The  consistence  of  the  excrement  is  no  doubt  a 
matter  of  some  importance  as  regards  the  action  of  the  large  bowel  and 
the  process  of  defecation.  In  different  animals  the  character  of  the 
faeces  varies  greatly,  and  we  meet  with  every  degree  of  difference 
from  the  extreme  of  dryness  and  firmness  to  the  very  opposite 
condition.  For  example,  the  faeces  of  the  rabbit  are  hard,  and  are 
almost  dry  before  they  are  expelled  from  the  bowel.  The  same,  too,  is 
the  case  with  the  sheep.  But  in  many  other  vegetable  feeders  the  con- 
tents of  the  large  intestine,  instead  of  becoming  inspissated  before  their 
expulsion,  are  very  largely  diluted  with  water.'  The  faeces  of  oxen  con- 
tain much  fluid,  while  those  of  the  horse  contain  comparatively  little. 
Such  facts  are,  of  course,  "explained  "  by  evolutionists,  according  to 
their  "laws"  of  evolution,  and  their  "laws"  of  the  correlation  of 
secretion,  excretion,  and  growth. 

The  too  rapid  absorption  of  fluid  should  doubtless  be  regarded  as 
one  of  the  circumstances  concerned  in  the  production  of  constipation. 
But  the  quantity  of  liquid  swallowed  may  be  defective,  and  the  undue 
inspissation  dependent  upon  actual  deficiency  of  fluid  in  the  organism 
instead  of  reabsorption.  Some  persons  habitually  take  too  much 
liquid,  others  too  little.  In  the  last,  the  fluid  part  of  the  blood  is 
probably  too  highly  concentrated  for  the  quick  removal  of  many  of  its 
constituents  by  the  secreting  cells  engaged  in  the  process.  The  various 
chemical  changes  under  such  circumstances  are  interfered  with,  or  do 
not  take  place  with  due  rapidity.  In  some  persons  many  of  the  secre^ 
tions  of  the  body  are  formed  in  too  large  a  quantity,  and  in  too  great 
a  degree  of  concentration,  and  cannot  be  thoroughly  dissolved  and 
washed  away  by  the  proportion  of  water  present. 

After  constipation  has  lasted  for  some  time,  as  I  have  already 
remarked,  various  constituents,  out  of  which  faecal  matter  is  ordinarily 
formed,  unduly  accumulate  in  the  blood,  and  cause  disturbance  in 
many  of  the  physiological  actions.  Derangement  of  the  general  health 
of  the  organism  follows.  There  may  be  suppression  as  regards  the 
formation  of  excrementitious  matters,  or  of  the  substances  out  of  which 
these  are  elaborated  by  gland-bioplasm  agency,  as  well  as  the  mere 
retention  or  accumulation  of  these  after  they  have  been  fully  formed. 
Aftei  a  person  has  been  living  long  in  town,  in  close  rooms,  too  much 


Il8     INFLUENCE  OF  CLOSE  CONFINEMENT  ON  THE  BLOOD. 

indoors,  taking  too  little  exercise,  and  especially  if  he  has  been  in  the 
habit  of  eating  too  much,  it  may  happen  that  the  blood  is  constantly 
only  imperfectly  aerated,  and  the  chemical  changes  which  end  in  the 
production  of  compounds  to  be  separated  by  various  glands,  and  at 
last  removed  altogether  from  the  organism,  have  not  taken  place  at  the 
proper  rate  nor  to  the  full  extent  that  is  desirable.  The  excretory 
processes  may  have  been  for  a  long  white  only  imperfectly  performed. 
Much  matter  which  ought  to  have  been  removed  will  have  accumulated 
in  the  blood  and  tissues  of  the  system,  and  may  have  done  harm  to 
tissues  and  organs.  Gout,  rheumatism,  or  other  ailment  may  in  con- 
sequence have  been  developed.  In  the  reduced  action  of  the  excreting 
apparatus  the  intestinal  glands  participate.  Too  little  faecal  matter  is 
formed,  and  of  the  amount  formed,  as  I  have  already  explained,  only  a 
portion  is  expelled  on  account  of  the  sluggish  state  of  the  nerves  and 
muscles  of  the  bowel.  Moreover,  reabsorption  of  soluble  matters  from 
the  large  intestine  proceeds,  and  the  materials  taken  up  add  to  the 
accumulation  of  excrementitious  matters  in  the  blood,  the  serum  of 
which  is  i-n  consequence  often  actually  changed  in  color  as  well  as  in 
composition.  The  general  health  soon  suffers,  the  clear,  florid  com- 
plexion of  health  disappears,  and  the  patient  becomes  sallow.  The 
color  of  the  skin  generally  is  dusky,  the  capillary  circulation  through 
the  tissues  miserably  sluggish,  the  intellect  dull.  There  is  an  indisposi- 
tion to  exertion  of  every  kind,  and  the  nervous  and  muscular  systems 
do  not  act  or  respond  to  a  stimulus  as  vigorously  and  as  quickly  as  they 
ought  to  do.  People  suffering  thus  may  go  on  with  their  work,  and  as 
a  fact  numbers  do  so — but  their  work  is  performed,  as  it  were,  against 
the  grain,  and  as  though  the  workers  were  heavily  weighted. 

If,  now,  for  a  time  the  conditions  under  which  existence  is  carried  on 
be  modified,  it  is  wonderful  how  great  a  change  will  take  place.  Per- 
haps for  the  first  few  days,  even  in  the  best  of  climates  and  amid  the 
most  beautiful  scenery,  the  interest  will  not  be  excited  or  the  despond- 
ency shaken  off.  Sleep  may  not  be  sound,  and  the  patient  on  rising  in 
the  morning  not  refreshed.  The  muscles  of  many  parts  of  the  body 
ache  ;  some,  and  particularly  those  in  the  front  of  the  leg,  may  feel  sore, 
and  after  much  walking  become  actually  painful.  The  patient  is  con- 
scious of  a  certain  stiffness  in  his  movements,  and  generally  the  elasticity 
both  of  mind  and  body  seem  to  be  for  the  time  impaired.  But,  before 
long,  a  change  takes  place.  The  appetite  improves  and  the  sensation 
of  hunger  returns.  Towards  evening  a  tired  feeling  is  experienced,  soon 
.succeeded  by  a  desire  for  rest.  Many  hours  of  sound  refreshing  sleep 
succeed,  and  the  patient  gets  up  a  different  man.  His  spirits  rise,  he  is 
seized  with  a  desire  to  see,  to  walk,  to  do.  The  mental  and  bodily 
lassitude  no  longer  troubles  him.  The  complexion  becomes  ruddy,  the 
skin  smooth,  and  moist,  and  healthy.  The  bowels  begin  to  act  freely, 


CONSTIPATION  AND  THE  HEALING  PROCESS,  Up 

and  in  three  or  four  days  the  excretory  glands  separate  from  the  blood, 
and  the  excretory  channels  discharge  in  twenty-four  hours  more  than 
had  previously  been  removed  in  a  week.  In  this  way  the  blood  is  soon 
depurated  and  changed  for  the  better,  and  I  have  no  doubt  that,  at 
least  in  many  cases,  the  improvement  in  mental  action  is  consequent 
upon  the  restoration  of  the  blood  to  its  normal  healthy  state.  There  is 
another  fact  which  may  be  adduced  in  favor  of  the  conclusion  that 
in  constipation,  or  imperfect  action  of  the  bowels,  the  blood  becomes 
altered  in  character.  If  you  happen  to  have  any  little  scratch  or 
abrasion  on  any  part  of  the  body,  it  will  look  more  or  less  "  angry  "  if 
the  excretory  processes  should  not  be  going  on  freely,  and  wounds  will 
not  heal.  Instead  of  healing  in  the  course  of  twenty-four  hours,  a 
scratch  will  discharge  altered  and  sometimes  irritating  liquor  sanguinis 
from  its  surface.  Healing  under  these  circumstances  goes  on  very 
slowly,  if,  indeed,  the  process  is  not  altogether  entirely  interfered  with 
for  a  time.  If  you  happen  to  be  troubled  with  any  little  cracks  about 
the  margin  of  the  mouth,  you  will  find  that  they  will  gape  and  give  you 
pain.  They  will  not  heal,  but  will  remain  open  for  several  days,  until 
free  action  of  the  bowels  occurs,  and  then  they  soon  improve  and 
gradually  get  well.  This  angry  state  of  scratches,  or  wounds,  or  little 
cracks  or  sores  on  the  lips  or  margin  of  the  tongue,  depends,  I  think, 
upon  an  altered  state  of  the  blood,  which  is  gradually  brought  about  by 
constipation. 

There  is  yet  another  matter  to  which  I  must  direct  attention, 
because  it  is  of  the  greatest  importance  in  connection  with  the  views  I 
have  advanced  concerning  the  state  of  the  blood  in  these  cases.  You 
will  often  meet  with  cases  in  which,  a  few  hours  after  a  surgical  opera- 
tion, the  temperature  of  the  blood  rises  three  or  four  degrees,  and  the 
patient  becomes  feverish.  The  pulse  increases  in  frequency.  There 
may  be  some  wandering  at  night  or  actual  delirium,  with  a  hot,  dry  skin, 
and  indeed  the  patient's  state  may  be  such  as  to  cause  his  attendant 
considerable  anxiety.  The  surgeon  examines  the  wound  and  finds  that 
instead  of  progressing  favorably,  it  looks  more  or  less  angry,  and  the 
discharge  on  its  surface  is  changed  in  character,  losing  its  viscidity  and 
becoming  thin  and  watery,  with  perhaps  a  little  softened  and  discolored, 
broken-down  blood  clot  mixed  with  it.  Now,  if  when  things  are  in  this 
state  you  give  a  purgative  which  will  act  freely  upon  the  bowels,  you 
will  perhaps  find  within  four  hours  after  the  purgative  has  been  taken, 
and  even  before  it  begins  to  act,  all  the  grave  symptoms  are  mitigated, 
and  the  patient  from  that  moment  will  progress  favorably.  I  have 
many  times  watched  with  interest  the  fall  in  temperature  in  such  cases 
— a  fall  of  some  three  or  four  degrees  of  Fahrenheit's  scale,  in  the 
course  of  a  few  hours,  from  the  action  of  a  purgative. 

Phenomena  of  the  same  general  nature  may  be  frequently  observed 


1 26  THE  BLOOD  IN  CONSTIPATION. 

in  young  children.  Many  troublesome  ailments  occurring  in  childhood 
are  due  solely  to  the  imperfect  action  of  the  bowels.  When  you  get 
into  practice,  oftentimes  you  will  be  called  to  see  a  child  who  seems 
extremely  ill,  is  irritable,  sleepless,  and  feverish,  perhaps  wanders  some- 
what and  screams  at  night,  perhaps  is  even  delirious.  Such  symptoms 
necessarily  cause  grave  anxiety  to  the  parents.  And  yet  serious  as  they 
appear,  all  these  untoward  symptoms  will  very  probably  be  completely 
relieved  as  soon  as  the  bowels  have  been  made  to  act  freely. 

The  facts  I  have  just  briefly  reviewed  prove  conclusively  that  the 
imperfect  action  of  the  large  bowel  may  derange  some  of  the  most  im- 
portant physiological  changes  going  on  in  the  system,  and  disturb  some 
of  the  most  important  organic  actions.  By  affecting  the  composition 
of  the  blood,  constipation  may  occasion  derangement  in  the  action  of 
many  secreting  organs  and  seriously  interfere  with  the  due  performance 
of  many  of  the  most  important  nervous  actions  and  impair  for  the  time 
the  intellectual  powers,  as  well  as  disturb  the  temper. 

Moreover,  you  will  find  that  the  particular  remedies  which  act  most 
advantageously  in  these  cases  of  derangement,  depending  upon  consti- 
pation or  imperfect  muscular  and  excretory  action  of  the  bowels,  are 
those  which  possess  the  special  property  of  exciting  various  secreting 
organs  to  increased  action.  Among  these  perhaps  the  most  useful  are 
preparations  of  mercury,  though  sudorifics  and  diuretics  not  unfrequently 
exert  a  beneficial  effect  without  any  purgation  whatever  being  produced. 
And  I  am  sure  that  you  will  not  fail  to  acknowledge  that  this  fact  also 
lends  support  to  the  view  that  the  composition  of  the  blood  is  modified 
by  persistent  constipation,  and  that  excrementitious  matters  which  ought 
to  be  quickly  excreted,  accumulate  in  it,  nutritive  operations  being  in 
consequence  deranged.  Lastly,  you  must  bear  in  mind  that  the  blood 
can  be  brought  back  to  its  normal  state  and  health  restored,  by  the 
action  of  those  remedies  which  have  the  property  of  exciting  the 
excreting  action  of  the  glands  of  the  intestine  and  other  parts  to  act 
very  freely,  and  thus  eliminate  from  the  blood  the  accumulation  of 
deleterious  excrementitious  matters. 

Piles  or  Haemorrhoids. — In  many  instances  constipation  .is  asso- 
ciated with  piles  or  haemorrhoids  («^a,  blood,  pew,  to  flow),  as  they  are 
termed,  which  consist  of  troublesome  little  nodules  about  the  orifice  of 
the  anus.  Sometimes  pendulous  papillae  form  on  the  mucous  mem- 
brane, half  an  inch  or  more  above  the  orifice.  These  infernal  piles 
gradually  enlarge  and  occasion  pain  and  inconvenience.  Each  in- 
cludes one  or  more  loops  of  vein,  with  a  number  of  dilated  capillaries. 
They  frequently  bleed,  and  sometimes  a  considerable  quantity  of  blood 
may  be  lost  in  this  way.  An  ordinary  pile  or  hsemorrhoid  is  a  small 
growth,  which  may  vary  much  in  shape,  but  which  depends  from  the 
general  surface.  The  .subcutaneous  or  submucous  areolar  tissue  is 


OF  THE   NATURE    OF  PILES.  121 

thickened,  and  the  small  vessels  dilated.  Little  irregular  varicose  dila- 
tations of  the  veins  can  be  seen  in  well-prepared  sections,  and  the  outer 
coat  of  the  vein  is  more  or  less  thickened  from  successive  attacks  of 
inflammation.  Dilated  veins  of  the  mucous  membrane  or  skin  near  or 
above  the  anus  often  exist  around  and  between  the  actual  hsemorrhoidal 
swellings.  Sometimes  the  pile  consists  of  spongy  tissue,  almost  like 
that  of  the  placenta,  and  undergoes  great  alteration  in  volume,  like  an 
erectile  tissue.  There  may  be  a  number  of  small  haemorrhoids  around 
or  within  the  anus,  each  gradually  increasing  in  size  until  it  is  as  large 
as  the  top  of  the  finger,  when  great  inconvenience  results.  Walking  is 
accompanied  by  much  suffering,  and  every  now  and  then  the  vessels 
become  more  congested  and  the  swelling  increases  in  size.  The 
tissues  around  the  dilated  vein  become  inflamed  ;  cracks  and  little  ulcers 
form,  and  severe  pain,  necessitating  complete  rest  in  the  recumbent 
posture  for  a  time,  is  the  result.  Gradually  this  inflammation  ceases. 
The  swelling  subsides  again  to  its  usual  dimensions,  and  perhaps  some 
time  may  pass  before  another  acute  attack  comes  on. 

Not  unfrequently,  clots  form  in  the  little  venous  pouches  and  irregular 
cavities.  The^brin  of  the  clot  gradually  contracts  and  thus  very 
hard  nodules  result.  These  remain  for  weeks  without  undergoing 
much  change,  but  gradually  the  coagula  are  absorbed  and  the  patient 
considers  himself  cured,  or  nearly  so.  But  soon  another  attack  occurs. 
Coagula  again  form  and  he  is  as  bad  as  before.  A  pile  or  hsemorrhoid 
which  attains  the  size  of  a  pea  is  seldom  cured  without  removal.  A 
Httle  surgical  operation  is  necessary,  and  then  the  patient  goes  on 
perhaps  perfectly  well  for  the  rest  of  his  life.  In  many  instances  there 
is  reason  to  think  the  development  of  piles  might  be  prevented  if  the 
bowels  had  been  made  to  act  pretty  freely  and  the  intestinal  canal  kept 
in  a  healthy  state  from  an  early  period  of  life.  It  is,  however,  some- 
times impossible  to  do  this  owing  to  hereditary  tendency  to  constipa- 
tion, or  to  structural  changes  in  glands  occurring  at  a  very  early  age. 
You  may  prevent  them  from  enlarging  rapidly  and  giving  trouble,  by 
making  the  patient  frequently  take  moderate  laxatives  and  attend  care- 
fully to  his  diet,  especially  as  regards  animal  food,  of  which  only  a  small 
portion  should  be  taken.  Most  persons  eat  far  too  much  meat  in  this 
country,  and  thereby  induce  many  slight  or  serious  derangements  of 
the  health. 

Primarily  the  condition  is  probably  due  partly  to  original  weakness 
of  vessels  and  to  a  relaxed  state  of  tissues,  to  the  so-called  scrofulous 
diathesis,  in  which  there  is  too  rapid  formation  as  well  as  imperfect 
hardening  and  condensation  of  tissue,  and  in  part  to  an  altered  state  of 
blood  which  interferes  with  the  formation  of  healthy  texture  having  the 
due  property  of  resistance.  The  dilatation  and  other  changes  in  the 
coats  of  the  veins  are  in  many  cases  general  and  not  restricted  to  the 
ii 


122  ASTRINGENTS  FOR  HEMORRHOIDS. 

haemorrhoidal  veins.  Want  of  exercise,  defective  oxygenation,  and 
generally  that  state  of  blood  which  favors  the  development  of  the  gouty 
and  a  certain  form  of  the  rheumatic  state,  seem  to  predispose  to  the 
formation  of  "piles"  in  various  parts  of  the  superficial  venous  system. 
Not  a  few  cases  of  "phlebitis  "  belong  to  this  category.  In  constipa- 
tion or  imperfect  action  of  the  bowels,  the  vessels  of  the  walls  of  the 
intestinal  canal  generally  are  somewhat  distended,  the  capillaries  almost 
constantly  unduly  distended  with  blood,  and  the  capillary  circulation 
slow  and  impeded.  The  blood  accumulates  in  the  veins  which  unite 
to  form  the  large  portal  vein.  The  flow  of  blood  through  the  liver  is 
affected,  and  the  portal  capillaries  in  the  lobule  become  habitually 
distended  with  blood,  and  the  action  of  the  liver  itself  is  of  course  much 
disturbed.  The  undue  tension  of  the  walls  of  the  portal  vessels  is 
oftentimes  temporarily  relieved  by  the  flow  of  fluid  into  the  intestinal 
canal,  as  occurs  in  diarrhoea,  or  after  the  administration  of  certain 
purgatives;  and  if, at  the  same  time  very  little  food  as  taken,  so  as  to 
allow  the  organs  loaded  with  inspissated  blood  to  rest  for  a  while, 
complete  recovery  may  take  place.  If  the  diet  be  regulated  and  the 
general  mode  of  living  be  corrected  in  cases  in  whi^h  it  has  been 
injudicious,  the  blood,  and  through  the  blood  the  various  tissues  and 
organs,  may  soon  regain  their  normal  state.  Sometimes,  as  I  have  said, 
relief  is  afforded  by  actual  haemorrhage  from  the  distended  veins,  and 
occasionally  the  capillaries  of  the  surface  or  the  mucous  membrane  give 
way,  and  thus  the  tension  is  relieved. 

Among  many  proximate  causes  of  haemorrhoids,  I  believe  conges- 
tion or  impeded  circulation  of  the  blood  in  the  portal  capillaries  of  the 
liver  is  not  an  uncommon  one.  In  many  persons  the  liver  often 
seems  to  act  sluggishly,  and  for  days  together  the  circulation  through 
it  is  much  impeded.  The  whole  organ  temporarily  increases  in  size  in 
consequence  of  its  vessels  being  distended  with  blood.  The  practitioner, 
under  these  circumstances,  directs  his  attention  to  relieving  the  conges- 
tion and  increasing  the  action  of  this  important  organ,  as  I  shall  describe 
further  on. 

An  astringent  ointment,  like  the  old  Compound  Gall  Ointment, 
Ungiientem  Gallce  Compositum,  applied  at  night,  is  certainly  useful  in 
the  early  stage  of  formation.  Attacks  of  congestion,  and  the  accumu- 
lation of  blood  in  the  vessels  which  are  productive  of  pain,  may  often 
be  prevented,  or  if  not  very  severe,  at  once  relieved  by  proper  treat- 
ment, particularly  by  paying  attention  to  the  action  of  the  liver  and 
bowels. 

For  the  sore  state  of  the  skin  and  mucous  membrane  between  or  over 
the  haemorrhoids,  as  well  as  for  healing  the  fissures  that  so  commonly 
form,  there  is  no  remedy  like  Vaseline;  but  you  must  be  careful  to  re- 
commend'your  patients  to  ask  for  the  pure  colorless  Vaseline,  for  the 


THE  ACTION  OF  ENEMATA.  1 23 

ordinary  substance  contains  irritating  matters  which  do  harm,  and  some- 
times interfere  with  the  healing  process. 

Of  the  Action  of  Enemata. — You  must  not  forget  that,  as  was  shown 
by  Marshall  Hall,  defecation  is  a  reflex  action,  and  is  dependent  upon 
the  contraction  of  the  muscular  fibres  caused  by  a  current  transmitted 
along  efferent  nerve-fibres  emerging  from  the  nerve-centre  which  receives 
the  sensitive  or  afferent  branches.  The  excitation  beginning  in  the 
peripheral  nerves  of  the  mucous  membrane  of  the  large  bowel  being  car- 
ried to  the  nerve-centre  by  the  afferent  fibres,  changes  are  produced  in 
the  centre  which  result  in  the  transmission  of  an  impulse  to  movement 
being  conducted  by  efferent  fibres  and  which  causes  contraction  of  the 
muscular  fibres.  The  afferent  nerves  in  the  mucous  membrane,  like 
many  special  fibres  in  other  parts,  seem  to  be  generally  in  a  quiescent 
state.  They  do  not  instantly  respond  to  very  slight  stimulus,  like  certain 
other  nerve-fibres,  as  for  example  those  spread  out  on  the  conjunctiva, 
but  decided  and  somewhat  prolonged  pressure  or  other  form  of  irrita- 
tion seems  to  be  necessary  to  throw  them  into  full  action.  In  many 
cases  of  constipation,  the  ordinary  stimulus  of  the  faecal  matter  present 
is  not  sufficient,  and  if  contraction  is  to  be  produced,  additional  excita- 
tion must  be  brought  about.  It  is  upon  this  principle  that  the  practice 
of  introducing  purgative  enemata  into  the  rectum  is  founded.  Ordinary 
water  may  be  gradually  injected,  and  in  this  way  the  contents  of  the 
lower  part  of  the  bowel  are  much  increased,  until  having  reached 
a  certain  volume,  powerful  reflex  action  occurs,  and  faeces  and  injection 
are  forcibly  expelled  together.  Do  not,  however,  suppose  that  the 
response  takes  place  immediately.  A  certain  interval,  perhaps  five  or 
ten  minutes  or  a  quarter  of  an  hour,  may  elapse  before  the  bowel 
contracts,  and  generally  it  is  better  that  the  contraction  should  not 
occur  too  quickly,  for  then  only  partial  expulsion  of  the  contents  may 
be  effected. 

In  administering  an  injection  you  should  direct  that  the  fluid  should 
be  introduced  very  slowly,  the  operator  stopping  for  a  time  whenever 
the  patient  feels. contraction  coming  on.  If  the  bowel  is  only  gradually 
distended,  you  will  often  find  that  a  pint  and  a  half  of  fluid  or  more 
may  be  introduced  before  reflex  action  is  excited.  This  simple  opera- 
tion, which  is  known  as  giving  a  Clyster,  or  Injection,  or  Lavement,  is 
a  practice  which  is  very  commonly  adopted,  and  some  people  are  in  the 
habit  of  resorting  to  it  very  frequently.  Some  of  the  French  ladies,  I 
am  told,  never  get  an  action  without  injecting  water  into  the  bowel,  and 
have  to  carry  out  the  practice  daily  or  every  other  day.  The  lavement 
is  an  efficient  but  rather  troublesome  measure  to  resort  to  daily,  and 
probably  few  English  people  could  be  persuaded  to  take  so  much 
trouble. 

Of  enema  syringes   there  are  numbers  constructed   upon  different 


124  PURGATIVE  ENEMATA. 

principles  and  made  of  different  forms.  The  simplest  are  made  of 
vulcanized  India-rubber.  The  most  ingenious  and  most  perfect  I  have 
seen  is  about  to  be  brought  out.  It  serves  more  than  one  purpose,  and 
will  be  of  the  greatest  service  both  to  practitioners  and  patients. 

Purgative  Enemata. — Instead  of  injecting  ordinary  water,  you  may 
employ  water  containing  various  purgative  medicines,  such  as  Colocynth, 
Aloes,  Castor  Oil,  or  some  others  dissolved  or  suspended  in  weak  gruel 
or  in  Soap  and  Water, 

In  making  a  purgative  enema  you  may  use  from  a  half  to  an  ounce 
of  soft  or  ordinary  yellow  soap  to  a  pint  of  warm  water;  with  this  two 
ounces  of  castor  oil  or  olive  oil,  or  half  an  ounce  of  turpentine,  may  be 
mixed.  Gruel  is  better  than  soap  and  water.  If  you  require  to  give 
an  aloes  or  colocynth  enema,  half  a  drachm  of  the  first  or  the  same 
quantity  of  a  drachm  of  the  compound  extract  of  colocynth  may  be 
well  rubbed  down  in  a  mortar  with  a  little  water  or  syrup,  and  then 
mixed  with  a  pint  of  gruel.  Two  or  three  drachms  of  the  Confection 
of  Rue,  in  the  proportion  of  three  drachms  to  a  pint,  is  a  good  addition 
in  cases  where  there  is  much  flatus  in  the  bowel. 

Sometimes  the  accumulation  of  faecal  matter  in  the  large  intestine  is 
so  considerable  that  the  bowel  becomes  almost  paralyzed,  and  the 
individual  cannot  expel  anything  by  the  strongest  efforts  he  can  make. 
Under  these  circumstances  you  may  inject  some  gruel,  or  plain  water, 
or  soap  and  water,  or  castor  oil  and  soap  and  water,  into  the  bowel,  and 
in  considerable  quantity,  without  succeeding  in  exciting  reflex  action. 
The  faeces  remain  as  it  were  impacted,  and  cannot  be  dislodged  by  such 
means.  This  condition  is  sometimes  spoken  of  as  impaction.  You 
may  occasionally  find  the  lower  part  of  the  large  bowel  of  an  old  person 
so  full  and  choked  by  impacted  fsecal  matter  that  it  overflows  as  it  were, 
although  there  is  not  the  slightest  effort  on  the  part  of  the  bowel  to 
empty  itself. 

As  the  bowel  does  not  contract,  and  has  indeed  nearly  lost  its  con- 
tractile power,  the  fascal  accumulation  must  be  removed.  A  sort  of 
scoop,  or  paper-knife,  or  the  handle  of  a  spoon,  or  any  other  convenient 
instrument  of  the  proper  shape  and  with  rounded  edges  so  as  not  to 
cut  the  parts,  may  be  used  to  remove  the  hard  faecal  matter.  The 
operation  is  always  a  disagreeable  one,  and  sometimes  it  is  very  difficult 
to  perform,  but  it  must  be  undertaken,  and  we  must  be  prepared  to 
interfere  in  this  way  many  times  in  the  course  of  our  practice.  Those 
of  you  who  may  by-and-by  be  engaged  in  country  practice  are  sure  to 
meet  with  such  cases  from  time  to  time,  particularly  amongst  the  inmates 
of  asylums  for  the  aged,  and  in  poor-houses,  and  you  must  be  ready  to 
afford  the  only  relief  that  is  possible. 


TREATMENT  OF  CONSTIPATION.  •      12$ 

THE  HYGIENIC  AND  DIETETIC  TREATMENT  OF  CONSTIPATION. 

There  are  certain  methods  of  preventing  and  treating  ordinary  con- 
stipation with  which  every  one  ought  to  be  acquainted.  By  having 
recourse  to  some  of  them  persons  who  have  suffered  may  not  only 
obtain  relief,  but  may  succeed  in  preventing  the  recurrence  of  the 
trouble. 

Exercise,  we  are  often  told,  is  a  great  preventive  of  constipation,  and 
sometimes  will  cure  it  when  established.  Many  practitioners  are  very 
confident  on  this  point,  and  invariably  assure  those  who  suffer  that  if 
only  they  will  take  sufficient  exercise,  they  will  be  cured.  Some  obedient 
patients  at  once  adopt  the  system  of  a  regular  constitutional.  But  here 
and  there  the  plan  completely  fails.  A  man  regularly  walks  his  six  or 
seven  miles  or  more  daily,  but  so  far  from  his  constipation  being  cured, 
he  may  perhaps  find  it  even  worse  than  before.  Exercise,  it  is  perfectly 
true,  is  advantageous  within  certain  limits.  But  if  a  person  takes  more 
exercise  than  is  good  for  him  he  may  actually  encourage  and  increase 
this  derangement  instead  of  curing  it.  Nor  is  walking  exercise  so  neces- 
sary or  advantageous  to  all  persons  as  is  generally  supposed.  Individuals 
differ  from  one  another  extremely  in  this  respect.  One  cannot  keep 
himself  in  health  without  his  long  dreary  daily  constitutional,  while 
another  enjoys  excellent  health  though  he  may  not  walk  a  mile  a  week. 
Not  only  so,  but  it  is  a  fact  that  many  persons,  particularly  women,  who 
have  taken  little  active  exercise  at  any  period  of  life,  have  nevertheless 
enjoyed  excellent  health  and  have  lived  to  be  very  old.  In  advocating 
exercise  in  constipation  and  in  other  slight  ailments,  you  must  be  care- 
ful in  the  case  of  those  who  have  not  been  accustomed  to  long  walks  to 
recommend  moderate  distances,  at  a  quiet  pace,  or  your  means  of  cure  may 
have  the  effect  of  doing  harm.  Two  or  three  miles  a  day  will  probably 
be  enough  for  most  persons.  The  man  who  is  engaged  in  hard  intel- 
lectual work  will,  as  a  rule,  require  little  exercise.  During  a  holiday  you 
may  engage  in  a  greater  amount  of  muscular  labor  than  you  could 
advantageously  perform  if  you  were  studying  hard.  And  I  have  known 
several  instances  of  persons  getting  thoroughly  out  of  health  in  conse- 
quence of  acting  upon  the  mistaken  notion  that  such  exercise  is  required 
at  the  same  time  that  intellectual  work  is  carried  on.  When  you  are 
working  for  an  examination,  and  reading  several  hours  clay  after  day, 
you  will  find  that  a  gentle  walk  for  an  hour  or  so  in  the  afternoon,  or 
spending  one  or  two  hours  in  the  open  air,  will  be  more  conducive  to 
your  progress  than  a  long  walk.  Fast  walking,  running,  and  all  violent 
athletic  exercises  should,  like  dinners  and  high  living  generally,  be 
avoided  by  those  who  are  preparing  themselves  for  examination. 

The  Cold  Bath  is  commonly  said  to  be  of  use  in  the  treatment  of 
constipation.  People  tell  us  that  if  we  indulge  in  cold  tub  every 
Ji* 


126  MOIST  APPLICATIONS   TO  STOMACH. 

morning  or  plunge  into  cold  water,  the  bowels  will  act  properly  and 
without  artificial  help  of  any  kind.  This  system  again  is  excellent 
for  some,  but  the  daily  use  of  cold  water  will  not  suit  all  equally  well. 
With  some  persons  it  disagrees  and  causes  them  to  feel  chilly  and 
uncomfortable.  On  cold  foggy  mornings  at  this  time  of  the  year 
(November)  it  requires  some  strength  of  mind  to  cover  oneself  with  cold 
water  just  after  turning  out  of  a  warm  bed.  Still,  many  Englishmen 
declare  that  it  not  only  suits  them,  but  affords  them  delight  and  keen 
enjoyment.  Those  with  whom  the  cold  bath  agrees  experience  a 
pleasant  glow  all  over  the  body,  and  feel  warm  and  in  good  spirits  for 
some  time  afterwards.  When  this  is  the  case,  you  may  advise  that  the 
cold  bath  should  be  continued.  But  if,  on  the  other  hand,  the  patient 
feels  chilly,,  miserable,  and  uncomfortable,  with  slight  headache  and 
chilliness  of  hands  and  feet,  and  especially  if  his  skin  should  get  cold 
and  bluish,  and  he  comes  down  to  breakfast  without  an  appetite,  you 
should  tell  him  that  cold  tub  in  the  early  morning  is  not  suitable  for 
him,  and  suggest  that  he  should  take  his  bath  tepid  or  even  warm. 

Rubbing. — Another  good  general  remedy.,  and  one  that  is  not  open 
to  any  objection,  is  rubbing.  I  believe  this  method  is  very  little  em- 
ployed, and  that  its  value  is  much  underrated.  There  are  many  who,  if 
instead  of  taking  a  cold  bath  would  simply  rub  themselves  well  with  a 
rough  towel,  using  strong  muscular  efforts  in  doing  so,  would  find  a 
gentle  glow  come  over  the  skin,  and  experience  a  far  more  comfortable 
sensation  than  is  afforded  by  a  cold  bath,  while  an  equal  amount  of  old 
epithelium  would  be  removed  from  the  cuticular  surface.  The  beneficial 
effects  of  rubbing  the  surface  are  probably  due  to  movement  of  the 
blood  in  the  cutaneous  capillaries,  caused  by  the  pressure  exerted. 
This  movement  of  the  blood  in  cases  where  there  is  a  tendency  to  its 
stagnation  in  the  capillaries  of  the  tissues  and  organs  is  of  the  greatest 
consequence,  and  must  be  borne  in  mind  as  an  important  principle 
which  must  not  be  lost  sight  of  in  the  treatment  of  many  derangements 
and  diseases. 

Moist  Application  to  the  Abdomen. — Persons  who  suffer  from  torpid 
bowels  are  often  much  relieved  by  the  application  of  a  \vet  compress 
over  the  stomach.  This  is  a  very  old  remedy.  You  may  apply  a  moist 
rag  or  towel,  folded  into  four,  to  the  surface  of  the  belly,  or  a  piece  of 
moistened  spongio-piline  may  be  used.  It  matters  not  whether  the 
water  be  cold,  tepid,  or  warm.  If  applied  cold  it  soon  becomes  warm, 
and  I  am  not  aware  that  any  benefit  results  from  the,  to  many 
persons,  very  unpleasant  application  of  a  cold  rag  to  the  warm  skin. 
Care  must  be  taken  that  the  compress  or  other  application  is  not 
too  wet  when  applied.  It  may  be  worn  for  two  or  three  hours  daily, 
and  :n  this  way  relief  is  often  obtained,  without  the  use  of  any  medicine 
whatever. 


DIET  IN  CONSTIPATION.  12? 

Of  Kneading  the  Bowels. — Another  very  simple  way  of  assisting  the 
action  of  the  large  bowel  is  to  press  or  knead  the  abdomen  with  the 
hands.  Any  one  can  do  this  for  himself.  The  two  hands  should  be 
moved  upwards  and  downwards  over  the  surface  of  the  belly,  and  the 
large  bowel  pressed  backwards  in  different  places.  Those  who  have 
studied  anatomy  know  the  course  taken  by  the  colon  round  the 
abdomen,  and  should  press  or  knead  it  in  a  direction  from  its  com- 
mencement in  the  csecum  in  the  right  iliac  region,  upwards,  and  across 
the  upper  part  of  the  belly  to  the  left,  and  then  downwards,  following 
the  ascending,  transverse,  and  descending  colon  towards  its  termination, 
in  the  rectum.  This  kneading  encourages  the  contraction  of  the  large 
bowel,  and  is  certainly  in  many  cases  useful. 

Diet. — There  can  be  no  doubt  that  diet  has  very  much  to  do  with 
the  regular  and  efficient  action  of  the  bowels.  A  liberal  allowance  of 
meat  and  a  too  highly  nutritious  diet  favor  constipation.  On  the 
other  hand,  various  kinds  of  fruit  and  many  vegetables  cooked  and  un- 
cooked, as  lettuces,  water-cresses,  and  mustard  and  cress,  tend  to  pre- 
vent and  relieve  constipation. 

Bread. — The  bread  that  we  eat  should  not  be  made  of  very  fine 
white  flour,  from  which  all  the  bran  has  been  carefully  separated^  and 
with  which  a  certain  proportion  of  alum — itself  possessing  astringent 
and  constipating  properties — has  been  added,  to  make  it  appear  per- 
fectly white.  The  best  bread  for  keeping  us  in  health  is  not  the 
whitest.  As  regards  pleasant  taste  and  nutritive  qualities,  the  sort  of 
bread  you  eat  at  farm-houses,  and  which  is  by  no  means  white,  is  much 
to  be  preferred.  Brown  bread,  such  as  we  get  in  London,  is  good,  but  it 
ought  to  be  made  of  flour  from  which  the  branny  particles  have  not  been 
separated  before  being  finely  ground.  I  fancy  that  a  good  deal  of 
brown  bread  is  made  by  adding  coarse  particles  of  bran  to  ordinary 
flour.  Brown  bread  taken  from  time  to  time  will  certainly  help  to 
excite  the  action  of  the  bowels.  The  whole  meal  bread  now  so  much 
recommended  is  doubtless  the  best  form  of  bread  to  take. 

Indian  corn  flour  is  one  of  the  most  wholesome  and  nutritious  forms 
of  food,  but  it  is  at  present  far  too  dear  to  be  used  as  staple  food ;  it  is 
much  to  be  desired  that  this  substance  should  be  brought  into  ordinary 
use. 

Oatmeal,  again,  is  another  good  and  very  desirable  kind  of  food.  It 
is  taken  by  many,  particularly  by  Scotch  people,  who  well  understand 
how  to  live  cheaply.  The  best  oatmeal  is  the  Scotch,  made  into 
"  stirabout."  It  may  be  cooked  in  many  ways.  Milk  may  be  added, 
or  it  may  be  formed  into  thin  cakes,  which  can  be  dried.  These  may 
be  toasted  when  required,  and  eaten  with  butter.  Oatmeal  sometimes 
proves  a  good  remedy  in  certain  forms  of  constipation.  In  it  all  mat- 
ters required  to  form  the  staple  of  ordinary  diet  are  found,  and  it  is 


128  LENITIVE  ELECTUARY. 

a  good  substitute  for  bread.  Some  persons,  however,  dislike  it,  and 
with  some  it  disagrees. 

Coffee. — A  small  cup  of  sweetened  black  coffee  (Cafe  ttoir)  before 
rising  sometimes  acts  as  a  purgative.  Some  persons  gain  the  same 
advantage  by  drinking  a  cup  of  tea. 

Fruit. — There  can  be  no  doubt  that  fruit  is  a  very  useful  article  of 
diet.  This  will  be  freely  acknowledged,  but  many  are  unable  to 
indulge  in  fruit  in  the  winter  season.  In  a  climate  like  ours,  except  for 
a  very  short  period  in  the  height  of  summer,  fruit  is  a  rather  expensive 
luxury.  However,  though  few  can  afford  to  obtain  as  much  fresh  fruit 
as  they  could  eat,  very  good  substitutes  are  within  the  reach  of  all, 
even  of  the  poor,  though  few  English  people  take  advantage  of  the 
opportunity  they  enjoy  of  being  able  to  purchase  excellent  dried  and 
preserved  fruit,  apples,  plums,  and  other  kinds  of  fruit,  at  a  very  cheap 
rate.  Oranges  and  lemons  are  also  to  be  had  during  the  greater  part 
of  the  year. 

French  Prunes  and  Apples. — Prunes  may  be  bought  for  a  few 
cents  a  pound,  and  a  pound  of  prunes  will  last  for  many  days.  If 
properly  prepared,  cooked  prunes  are  very  good.  The  French  and  the 
Germans  use  prunes  very  generally.  They  stew  them  and  add  some 
syrup,  and  eat  them  with  the  meat  at  dinner  almost  daily.  If  you 
determine  to  try  them,  you  may  have  to  turn  cook  for  a  time,  for  you 
will  find  few  British  cooks  disposed  to  follow  your  directions.  Should 
the  cook  be  exceptionally  amiable  and  willing  to  learn,  you  may  suggest 
to  her  some  such  plan  of  proceeding  as  the  following: — The  prunes 
may  be  soaked  in  cold  water  for  several  hours,  perhaps  twelve  hours 
or  longer.  When  they  are  found  to  have  swollen  up,  and  to  have 
become  quite  soft,  in  consequence  of  imbibing  much  cold  water,  they 
may  be  stewed  in  the  ordinary  way,  and  sugar  added.  If  properly 
cooked,  they  will  be  perfectly  soft  and  of  a  very  pleasant  flavor.  In 
this  way  you  can  all  provide  yourselves  with  perfectly  good  fruit  all  the 
winter.  You  may  also  recommend  French  plums,  which  are  nicer 
than  ordinary  prunes,  but  more  expensive. 

Lenitive  Electuary  {Confectio  Senna  composite?)  contains  prunes. 
Although  this  is  a  very  good  purgative,  you  will  find  that  some  people 
do  not  like  it.  Children  will  often  take  stewed  prunes,  although  it  is 
a  most  difficult  matter  to  give  them  any  form  of  medicine.  You  may 
increase  the  purgative  properties  of  stewed  prunes  in  a  very  simple  way 
— and  the  hint  I  shall  give  you  is  a  useful  one  to  bear  in  mind  in  the 
management  of  children.  Suggest  that  a  teaspoonful  of  Senna  leaves 
be  tied  up  in  a  small  muslin  bag  and  soaked  for  an  hour  in  the  water 
in  which  a  pound  of  prunes  is  stewed.  In  this  way  you  add  a  little 
infusion  of  Senna  to  the  prunes,  and,  although  you  hardly  alter  their 
taste,  you  considerably  increase  their  purgative  action. 


OF  TAKING  SUFFICIENT  FLUID.  1 29 

Apples  dried. — Another  fruit  you  can  always  get  is  dried  apples. 
They  are  ordinarily  sold  now  at  all  the  grocers.  These  you  will  find 
to  be  an  agreeable  change,  and  may  take  the  place  of  the  prunes.  They 
must  be  soaked  in  water  for  a  few  hours,  and  then  stewed  in  the  ordi- 
nary way.  A  pound  of  these  will  be  sufficient  for  several  dishes.  Of 
late  apples  have  been  introduced  in  a  new  form.  Thin  shavings  of 
apples  dried  in  the  sun,  retain  their  flavor  so  thoroughly  that  when 
moistened  and  cooked  you  could  not  distinguish  them  from  fresh 
apples. 

Another  dried  fruit,  which  is  now  very  cheap  and  to  be  obtained  in 
good  order  all  the  winter,  is  the  dried  fig.  Figs  are  now  brought  over 
in  large  quantities,  and  are  very  cheap.  The  purgative  action  is  in- 
creased by  soaking  in  water  over  night.  The  fig,  in  a  state  of  soft  pulp, 
may  be  eaten  on  the  following  morning. 

Of  Taking  Fluid. — The  quantity  of  fluid  taken  has  some  influence 
upon  the  action  of  the  bowels.  Many  people  are  seldom  thirsty,  and 
more  object,  and  with  good  reason,  to  drinking  water.  Tea  is  often 
discarded  on  the  supposition  that  it  causes  indigestion.  If  tea  and 
coffee  and  alkaline  and  effervescing  waters,  and  all  forms  of  alcohol, 
are  objected  to  by  the  medical  adviser,  as  not  uncommonly  happens, 
the  unfortunate  patient  will,  in  his  efforts  to  comply  with  very  unreason- 
able advice,  probably  take  too  little  fluid  in  the  twenty-four  hours,  and 
thus  disturb  many  of  the  chemical  changes  going  on  in  his  body.  One 
cupofteaormilkand  water,  at  breakfast,  half  a  pint  of  beer  in  the  middle 
of  the  day,  and  perhaps  another  half  a  pint  of  beer,  or  wine  in  water  at 
dinner,  will  scarcely  amount  to  a  sufficient  quantity  of  fluid  to  keep  the 
body  in  health,  especially  if  the  appetite  is  good,  and  a  fair  amount  of 
solid  food  is  consumed.  People  who  are  never  thirsty  will  occasionally 
suffer  from  constipation,  as  well  as  from  other  derangements,  which  will 
be. referred  to  in  their  proper  place. 

When  you  have  reason  to  think  that  a  patient  is  suffering  in  health 
from  taking  too  little  fluid,  you  may  suggest  to  him  the  propriety  of 
taking  a  certain  quantity  of  water  at  fixed  times.  You  recommend  him 
to  drink  a  glass  of  ordinary  water  on  rising,  another  about  eleven  o'clock, 
and  another  at  bed-time.  Or  you  may  suggest  that  at  dinner  he 
should  take  hock  and  seltzer  water,  and  an  hour  after  dinner,  or  at  bed- 
time, another  glass  of  seltzer,  or  some  other  effervescing  water.  In 
some  cases  you  may  recommend  cider  or  perry  to  be  taken  at  dinner. 
You  may  advise  that  broth  should  form  part  of  the  most  important  meal 
of  the  day,  and,  generally,  you  suggest  various  things — milk,  whey,  more 
tea,  linseed  tea,  or  barley  water,  etc. — with  the  object  of  getting  more 
fluid  into  the  body. 

I 


130  MEDICINAL    WATERS. 

In  general  it  does  not  do  to  advise  the  patient  to  take  ordinary 
water,  for  in  the  first  place,  few  would  adopt  your  prescription,  and, 
secondly,  there  is  the  real  and  serious  objection  that  ordinary  water  may 
be  bad  and,  though  not  disagreeable  to  the  taste,  may  contain  typhoid 
fever  or  other  disease  germs.  All  objections  to  ordinary  water  are, 
however,  removed,  if  it  be  boiled.  Some  do  not  dislike  taking  warm 
tea  or  warm  water  with  their  meals.  Either  often  suits  the  stomach  far 
better  than  cold  fluid,  which  sometimes  checks  digestion.  In  cold 
weather  I  have  long  been  in  the  habit  of  taking  warm  water,  and  have 
recommended  the  practice  to  others,  but  many  object  and  prefer  to  let 
the  water  get  quite  cold  before  they  drink  it.  Householders  should 
make  a  rule  that  every  morning  a  kettle  of  water  that  has  been  boiled 
for  ten  minutes  or  longer  should  be  allowed  to  cool,  and  then  poured 
on  the  filter.  The  boiling  renders  the  water  perfectly  safe,  for  it 
destroys  every  living  organism  as  well  as  any  animal  poisons  that  may 
be  suspended  in  it. 

Most  practitioners  recommend  their  patients  to  drink  special  aerated 
waters,  and  there  is  no  doubt  that  some  of  these  are  more  pleasant  to 
the  taste  than  is  ordinary  water,  but  the  rapidity  with  which  waters  of 
particular  kinds  come  into  favor  and  are  forgotten,  and  give  place  to 
others,  is  sufficient  to  show  that  the  water  is,  after  all,  the  active  and 
efficient  ingredient.  The  patient  who  goes  to  some  celebrated  spa  is  no 
sceptic,  and  according  to  the  instruction  he  has  received  from  his 
teacher,  attributes  the  beneficial  effects  he  experiences,  not  to  the 
ingredients  dissolved  in  the  water,  but  to  some  mysterious  properties 
which  these  substances  are  supposed  to  have  somehow  acquired  as  they 
were  dissolved,  or  while  the  solution  was  being  forced  upwards  through 
the  soil  to  the  surface  of  the  ground.  The  potash  and  soda,  etc.,  ac- 
cordingly are  not  ordinary  potash  and  soda,  with  the  ordinary  proper- 
ties of  the  molecules,  but  are  imbued  with  some  very  remarkable 
powers  somehow  communicated  to  them  in  the  bowels  of  the  earth. 
Fashion  and  caprice  sanction  and  demonstrate  the  universal  healing 
powers  of  this  or  that  spring,  and  then  a  new  fashion  decrees  its  impo- 
tence and  transfers  infallible  potencies  to  some  newly-discovered  water. 
The  self-denying  supplicant  who  determines  to  devote  himself  for  a  few 
weeks  to  the  worship  of  Hygeia  must  turn  out  at  about  five  A.  M.,  and, 
according  to  the  established  rites  of  the  place,  may  have  to  walk  a  cer- 
tain distance,  and  drink  a  definite  quantity  of  water,  before  he  is  per- 
mitted to  enjoy  the  frugal  breakfast,  at  which  even  butter  is  often 
proscribed.  More  drinking  and  more  walking  follow  in  due  course,  in 
obedience  to  well-defined  rules.  The  simple,  midday  meal  is  succeeded 
by  more  walking,  more  air,  and  more  water.  Improvement  is  soon 
manifested.  The  bowels  act,  the  appetite  returns,  the  spirits  rise,  and 
due  credit  ir>  given  to  the  mysterious  agencies  communicated  to  some  of 


TREATMENT  OF  CONSTIPATION.  13! 

the  chemical  ingredients  of  the  water  during  their  solution  or  afterwards. 
The  air,  the  simple,  wholesome,  and  restricted  diet,  the  substitution  of 
water  for  alcohol,  the  exercise,  the  rest  enjoyed,  and  peace  of  mind  are 
the  mere  accidents  attending  the  curative  action  of  the  special  water. 
But  those  who  drink  good  water  in  London,  and  live  according  to 
reason,  may  work  hard  and  enjoy  all  the  year  round  the  advantages 
which  some  go  so  far,  and  at  great  expense  and  inconvenience,  to  try 
to  find  during  what  they  call  their  holiday. 

Smoking  Tobacco. — Other  unfortunate  individuals,  slaves  to  a  bad 
habit,  tell  you  they  never  can  get  their  bowels  to  act  without  smoking 
the  accustomed,  cigar  or  pipe.  Whether  it  be  the  force  of  habit,  or 
whether  the  nicotine,  the  active  principle  of  the  tobacco,  actually  gets 
into  the  blood  and  excites  the  bowel  to  act  through  the  nerve-centres,  I 
do  not  know,  but  we  are  often  assured  that  smoking  does  exert  a  purga- 
tive influence.  Tobacco  smoking  in  moderation  certainly  does  no 
harm  whatever,  and  he  who  finds  that  it  is  followed  by  the  desirable 
consequences  referred  to,  will  be  wise  to  smoke. 

THE  MEDICINAL  TREATMENT  OF  CONSTIPATION. 

Of  Purgatives  in  Constipation. — As  I  have  shown,  in  cases  of  pro- 
longed insufficient  action  of  the  bowels,  the  general  health  is  impaired, 
the  blood  becomes  altered  in  composition,  many  substances  remaining 
in  it,  and  circulating  with  it  through  the  vessels,  which  ought  to  have 
been  eliminated,  and  the  action  of  many  secreting  and  other  organs  is, 
in  consequence,  more  or  less  disturbed.  This  after  a  time  may  lead  to 
structural  change,  and  result  in  disease. 

It  may  be  necessary  to  advise  the  patient  who  has  been  suffering 
from  deranged  health,  resulting  from  a  prolonged  state  of  constipation, 
to  submit  to  systematic  medical  treatment.  In  some  instances  the 
condition  may  be  relieved  by  attending  to  the  state  of  the  secreting 
organs  without  giving  any  medicines  having  purgative  properties.  The 
character  of  the  urine  and  other  secretions  is  often  much  altered. 
Deposits  of  considerable  quantities  of  urates  are  formed,  and  the  urine 
itself  may  be  of  very  high  specific  gravity,  and  in  other  respects  may 
have  departed,  more  or  less,  from  the  healthy  state.  In  such  cases  a  few 
doses  of  Bicarbonate  of  Potash  (Potasses  Bicarbonas)  will  set  everything 
to  rights  in  a  day  or  two,  without  any  purgative  action  being  excited. 

In  many  cases  of  constipation  in  which  the  blood  is  in  such  a  state 
that  any  little  wounds  or  scratches  do  not  quickly  heal,  an  ordinary 
purgative  that  acts  on  the  alimentary  canal  will  not  suffice,  but  you 
must  select  one  which,  besides  'producing  purgation,  also  acts  upon  the 
secreting  glands,  particularly  those  which  discharge  their  secretions 
at  once  into  the  alimentary  canal.  As  soon  as  the  medicine  begins  to 
act,  and  that  is  oftentimes  hours  before  any  purgative  effect  is  ex- 


IJ2  MEDICINAL    TREATMENT. 

perienced,  the  red  and  angry  appearance  of  the  wounds  and  scratches 
will  subside,  and  the  healing  process  will  be  proceeding  satisfactorily 
within  twenty-four  hours  after  the  dose  has  been  swallowed. 

Where  constipation  has  existed  for  a  considerable  period  of  time, 
'and  the  general  health  has  in  consequence  become  considerably  de- 
ranged, you  must  not  expect  that  the  patient  is  to  be  at  once  cured, 
and  indeed  generally  you  will  find  that  purgatives  administered  from 
time  to  time,  in  moderate  doses,  act  more  favorably  than  a  smart 
purge  administered  once  only.  Very  free  purgation  is  often  followed  by 
constipation,  and  the  patient,  instead  of  being  permanently  benefited,  is 
only  relieved  for  a  very  few  days.  You  will  often  find  it  necessary  to 
give  moderate  doses  of  certain  purgative  medicines  at  short  intervals 
for  a  time,  taking  care,  however,  not  to  carry  this  system  too  far,  so  as 
to  worry  and  irritate  the  alimentary  canal,  and  give  the  patient  much 
pain  and  discomfort.  Again,  it  not  unfrequently  happens  that  an 
ordinary  purgative  will  not  properly  act,  or  it  acts  only  very  slightly, 
without  affording  the  relief  which  is  expected.  In  such  a  case  it  may 
be  advisable  to  repeat  the  medicine  two  or  three  days  running,  but  some- 
times it  is  better  to  wait  for  a  few  days,  and  then  repeat  the  dose.  The 
same  observation  has  been  made  as  regards  many  other  medicines. 
Bicarbonate  of  Soda  or  Potash  often  fails  to  relieve  if  given  in  single 
doses,  though  they  be  large,  while  if  fifteen  or  twenty  grains  be  taken 
three  times  a  day,  and  continued  for  three  or  four  days  a  week,  a 
very  distinct  and  highly  satisfactory  effect  is  produced. 

The  same  medicine  administered  to  a  person  in  precisely  the  same 
dose  will  sometimes  act  freely  and  sometimes  will  not  act  at  all.  The 
state  of  the  bowel  varies  greatly  as  regards  secretion,  and  its  response 
to  stimulants  to  secretion  and  muscular  contractility.  No  doubt  this 
depends  to  some  extent  on  the  appetite,  and  the  kind  and  amount  of 
food  taken,  but  not  entirely  so,  for  sometimes  after  a  person  has  lived 
sparingly  for  some  time,  a  moderate  purge  will  produce  a  very  free 
action.  The  action  of  the  intestinal,  like  that  of  other  glands,  is  not 
uniform  within  corresponding  periods  of  time,  but  sometimes  it  is  very 
free,  sometimes  almost  suspended  for  a  while.  If  we  can  just  hit  upon 
the  time  when  the  glands  are  about  to  act  freely,  for  the  administration 
of  the  purgative,  the  effect  will  be  exactly  what  is  desired.  Most  glands 
form  and  discharge  their  secretions,  and  then  rest  for  a  while.  It  is, 
therefore,  wrong  in  principle  to  be  continually  trying  to  excite  them  to 
action  by  giving  remedies  which  excite  free  action,  day  after  day,  for 
a  considerable  period.  This  injudicious  and  unreasonable  practice, 
which  was  much  in  favor  fifty  years  ago,  did  weak  people  a  good  deal 
of  harm,  and  to  it  we  are  indebted  for  the  present  unreasonable  oppo- 
sition to  the  employment  of  one  of  the  most  valuable  medicines  (mer- 
cury) known  to  us. 


SLUGGISH  BOWELS.  133 

When  the  constipation  depends  upon  sluggish  action  of  the  large 
bowel  only,  the  daily  or  almost  daily  administration  of  a  mild  purge, 
containing  Rhubarb,  Aloes,  Senna,  Colocynth,  or  Podophyllin,  is  un- 
objectionable, and  by  adopting  this  practice,  which  has  been  solemnly 
condemned  by  some  authorities,  you  will  sometimes  enable  a  patient  to 
get  through  a  great  deal  of  work  which  otherwise  he  could  not  perform, 
and  you  will  now  and  then  succeed  in  transforming  a  thoroughly  miser- 
able and  discontented  person  into  a  happy  one.  See  also  the  remarks 
on  the  use  of  mercury  under  the  "  Treatment  of  Sick-headache." 

One  is  often  assured  by  a  patient  in  answer  to  inquiries  that  his 
bowels  are  "  regular,"  that  is,  that  an  action  occurs  every  day,  and  he 
will  perhaps  tell  you  that  he  is  quite  confident  no  purgative  medicine  is 
required.  Although  from  the  first  you  suspect  that  he  requires  a  purge, 
according  to  his  wish  you  try  various  remedies  to  relieve  the  symptoms 
of  which  he  complains,  but  without  effect.  He  may  go  from  doctor  to 
doctor,  and  at  last  he  is  ordered  to  take  a  purgative,  and  gets  almost 
immediate  relief.  Oftentimes  it  is  necessary  to  order  a  mild  purgative 
pill  to  be  taken  daily  before  dinner,  for  a  week  or  longer,  and  the 
patient  is  not  unfrequently  quite  astonished  at  the  effect.  Up  to  that 
time  he  had  felt  convinced  that  his  colon  was  clear,  although,  in  fact, 
faecal  matter  had  been  very  gradually  accumulating  in  it  for  a  consid- 
erable time. 

You  will  often  find  small  doses  of  purgatives,  given  just  after  food 
for  several  days  in  succession,  of  great  use  in  imperfect  action  of  the 
bowels,  from  which  many  persons  engaged  in  sedentary  pursuits  in 
towns  very  commonly  suffer.  From  three  to  ten  grains  of  Rhubarb, 
with  or  without  Carbonate  of  Soda,  or  five  grains  of  Compound 
Rhubarb  pill,  will  be  sufficient.  You  must  teach  people  to  experiment 
a  little  on  themselves,  in  order  that  they  may  find  out  the  least  quantity 
required  to  produce  the  effect  desired.  As  before  remarked,  fruit  taken 
daily  is  of  use  in  such  cases,  but  many  persons  do  not  try  the  plan  long 
enough  to  obtain  success.  The  digestive  organs  which  act  sluggishly 
require  a  good  deal  of  humoring,  so  to  say.  Violent  purgatives  are  worse 
than  useless,  and  in  such  cases  a  moderate  purge  is  often  followed  by  a 
headache  and  general  upset,  lasting  perhaps  for  many  days,  and  suc- 
ceeded by  the  sluggish,  torpid,  imperfectly  acting  state.  There  is  no  diffi- 
culty in  managing  those  who  eat  well  and  take  plenty  of  exercise,  but 
those  who  live  very  moderately,  and  whose  work  is  intellectual  rather 
than  muscular,  will  require  some  thought  and  the  exercise  of  a  little 
ingenuity  on  your  part  to  get  them  right,  and  to  regain  for  them  the 
much  desired  feeling  of  contentment  dependent  upon  healthy  intestinal 
action. 

As  regards  the  doses  of  purgatives,  you  must  be  very  careful,  for 
you  may  order  a  patient  a  dose  that  will  certainly  clear  out  the  whole 

12 


134  CALOMEL  AND  COLOCYNTH. 

intestinal  canal,  but  which  will  also  gripe  him  very  severely,  and  make 
him  for  a  time  very  weak  and  miserable  ;  while  a  dose  which  you  might 
perhaps  hardly  believe  would  have  any  purgative  action  at  all,  would 
have  been  quite  sufficient  to  effect  the  desired  end,  and  without  pro- 
ducing the  slightest  pain  or  discomfort.  You  must  vary  the  doses  of 
the  drugs  you  prescribe,  according  to  the  state  of  the  patient,  and 
according  to  the  sort  of  organism  you  have  to  treat.  If  you  are  pre- 
scribing for  a  highly  nervous,  anxious,  excitable  person,  who  thinks  he 
has  got  all  sorts  of  ailments  of  a  very  serious  character,  you  must,  as  a 
rule,  not  give  very  violent  purgatives,  for,  if  you  do,  you  may  bring  on 
pain  and  sickness,  and  much  increase  the  intensity  of  the  suffering  you 
have  been  asked  to  alleviate.  On  the  other  hand,  if  you  are  treating  a 
robust  laboring  man,  accustomed  to  work  hard  and  feed  well,  and  in 
the  habit  of  drinking  three  or  four  pints  of  beer  a  day,  and  more  when 
he  can  get  it — who  has  a  florid  complexion  and  great  muscular  vigor,  it 
would  be  foolish  to  order  him  a  gentle  pill  or  mild  draught.  To  such  a 
person  two  or  three  grains  of  Colocynth  pill  would  be  perfectly  useless, 
and  ten  grains  might  be  required  to  act  at  all,  and  if  you  were  to  add  to 
these  two  or  three  grains  of  Calomel,  the  patient  would  probably  feel  the 
more  grateful  to  you.  Many  of  the  chemists,  in  town  and  country,  sell 
good  strong  pills,  and  which  are  most  useful  for  those  for  whom  they  are 
prepared,  though  they  would  not  suit  many  of  your  patients.  This  neces- 
sity for  varying  thedoses  of  medicines  according  to  the  individual  patient, 
ought  to  convince  all  of  the  importance  of  each  practitioner  learning  how 
to  prescribe,  and  mix,  and  combine  medicines,  instead  of  exclusively 
relying,  upon  the  pills  and  mixtures  prepared  for  the  profession  in 
enormous  quantities  by  large  firms,  and  to  be  purchased  by  the  gross  and 
by  the  gallon,  but  which  cannot  be  altered  to  suit  individual  patients,  and 
combined  so  as  to  agree  with  peculiar  temperaments.  Moreover,  there 
is  no  doubt  that  many  extracts  and  pill  constituents  lose  much  of  their 
virtue  by  being  kept  for  a  considerable  time.  Practitioners  have,  from 
time  to  time,  discovered  certain  combinations  of  things  which  are  very 
valuable,  and  the  receipt  for  many  a  useful  pill  or  mixture  has  been 
handed  down  from  generation  to  generation.  In  these  days,  not  only 
do  we  neglect  to  use  many  of  the  old  prescriptions,  but  we  no  longer 
suggest  new  ones,  and  many  combinations  of  drugs  of  tried  value  and  in 
frequent  use  in  former  days,  will  soon  be  altogether  forgotten.  The  old 
system  of  teaching  such  elementary  but  practically  important  matters 
has  been  entirely  abandoned,  and  many  a  wrinkle  of  the  greatest  im- 
portance in  practice,  instead  of  being  preserved  and  transmitted  as 
formerly  from  master  to  pupil,  has  been  lost.  Let  me  advise  you 
never  to  neglect  an  opportunity  of  picking  up  from  old  practitioners 
any  receipts  for  medicines  they  are  willing  to  give  you,  and  not  to 


CASTOR-OIL  AND  RHUBARB.  135 

despise  their  teaching,  especially  as  regards  the  treatment  of  many 
slight  ailments  difficult  to  manage  and  to  cure.  Do  not  receive  with 
contemptuous  indifference  their  'suggestions  for  the  treatment  of  func- 
tional disorders,  the  exact  nature  of  which  they  may  be  unable  to 
adequately  explain. 

Castor-Oil,  Oleum  Ricini,  which  is  the  oily  substance  expressed 
from  the  seeds  of  the  Ricinus  communis,  is  one  of  the  best  and  most 
frequently  used  of  purgative  medicines,  and,  were  it  not  for  its  nauseous 
flavor  would  be  yet  more  popular.  It  is  at  the  same  time  one  of  the 
mildest  and  most  certain. of  purgatives,  and  is  suitable  to  persons  of  all 
ages.  You  may  give  it  to  the  infant  as  well  as  to  the  most  infirm  and 
delicate.  It  is  usually  given  by  the  mouth.  But  Castor- oil  may  also  be 
employed  in  enemata.  It  is  one  of  the  few  purgatives  that  act  upon 
every  part  of  the  intestinal  canal,  from  the  stomach  downwards,  but  its 
action  commences  in  the'  upper  part,  and  it  is  efficient  in  driving  down 
imperfectly  digested  and  other  matters  that  may  be  irritating  the 
mucous  membrane  and  causing  pain.  The  dose  varies  from  a  few  drops 
to  half  an  ounce  or  more,  but  most  persons  take  more  Castor-oil  than  is 
really  necessary  to  produce  the  required  effect.  One  teaspoonful  is  often 
sufficient  for  an  adult,  and  sometimes  acts  as  well  as  a  larger  dose. 
Not  the  least  advantage  of  prescribing  the  smallest  dose  that  will  be 
useful  is  that  it  is  so  much  easier  to  take.  There  are  many  receipts  for 
taking  Castor-oil  so  as  to  avoid  tasting  it.  Upon  the  whole  I  think  you 
will  find  the  following  one  of  the  most  efficient  plans.  You  direct  that 
a  teaspoonful  or  more  of  "  black  coffee,"  that  is,  coffee  without  milk,  be 
poured  into  a  wineglass,  the  whole  of  the  interior  of  which,  including 
the  lip,  has  been  well  wetted  with  the  coffee.  A  teaspoonful  or  a  little 
more  of  the  oil  is  then  to  be  steadily  poured  on  the  surface  of  the 
coffee,  when  it  will  form  a  large  globule  lying  perfectly  free  and  not  in 
actual  contact  with  any  part  of  the  glass,  because  the  latter  has  been 
well  wetted  with  the  adhering  coffee.  The  patient  then  opens  his  mouth 
wide  and  pours  the  oil  and  coffee  down  his  throat,  swallowing  the  whole 
in  one  gulp.  If  the  operation  has  been  successfully  conducted,  he  will 
not  have  tasted  the  oil  in  the  slightest  degree.  Tea,  a  little  Ginger  or 
Orange  Wine  and  water,  or  Peppermint,  Camphor  or  Orange-flower 
water,  or  Brandy  and  water  may  be  used  instead, — but  strong  spirit 
being  lighter  than  the  oil  will  not  do.  Some  strongly  recommend  that 
the  dose  of  Castor-oil  should  be  well  shaken  up  in  a  bottle  with  twice 
its  quantity  of  milk,  and  when  well  incorporated  poured  into  a  cup  or 
glass  and  quickly  swallowed. 

Rhubarb,  Rhei  Radix,  Pulvis  Rhei  is  one  of  the  best  of  purgatives, 
and  its  virtues  are  very  widely  known.  It  has  been  a  popular  remedy 
for  more  than  two  centuries,  and  is  one  of  the  best  purgatives  for 
children.  Mixed  with  Carbonate  of  Soda,  Soda  Bicarbonas,  it  is  very 


136  COMPOUND  RHUBARB  PILL. 

useful  in  derangements  of  digestion.  From  five  to  twenty  grains  of 
Rhubarb  with  twice  as  much  Bicarbonate  of  Soda,  will  often  give  great 
relief.  The  dose  may  be  repeated  once  every  other  day  after  food  for  a 
week  or  two  in  cases  of  constipation  or  imperfect  action  of  the  bowels. 
See  also  pp.  139,  141. 

Pulvis  Rhei  Composilus,  formerly  known  as  Gregory1  s  Powder,  con- 
sists of  Rhubarb,  2,  Light  Magnesia,  6,  and  powdered  Ginger,  i.  It 
is  an  excellent  and  safe  remedy  and  may  be  given  in  doses  of  from  ten 
grains  to  a  drachm,  in  water. 

Ordinary  Compound  Rhubarb  Pill,  Pilula  Rhei  Composita,  and 
Compound  Colocynth  Pill,  Pilula  Colocynthidis  Composita,  suit  most 
persons  very  well.  You  may  order  three  to  eight  grains  of  either  of 
these  pills,  and  it  is  better  to  combine  with  them  a  grain  or  two  of  the 
Extract  of  Hyoscyamus  or  Henbane,  Exlractum  Hyoscyami,  which  will 
prevent  any  griping  or  discomfort.  Three  or  four  grains  of  either  of 
the  above  pills  with  a  grain  of  Extract  of  Henbane  may  be  made  into 
a  pill,  and  one  may  be  taken  every  night  or  every  other  night  for  a 
week  or  two,  in  many  cases  with  great  advantage.  In  this  way  the 
bowels  may  be  thoroughly  relieved  and  got  into  the  way  of  working 
regularly. 

One  of  the  great  advantages  of  giving  purgative  medicines  in  the 
form  of  pills  is  that  the  particles  of  the  drug  are  thoroughly  comminuted 
and  diluted,  as  it  were,  by  less  active  ingredients.  The  importance  of 
the  minute  division  of  active  substances  was  known  even  to  the  ancients. 
A  smaller  quantity  of  the  active  material  is  sufficient,  and  it  is  far  less 
likely  to  do  harm,  while  its  action  is  sure  to  be  more  moderate  and 
equable,  if  intimately  mixed  with  a  quantity  of  inert  or  slightly  active 
material,  than  if  administered  in  a  pure  state.  Many  pills  and  powders 
have  been  compounded  on  this  principle.  Compound  Ipecacuanha 
powder,  Pulvis  Ipecacuanha  Compositus,  Compound  Jalap  powder, 
Pulvis  Jalaptz  Compositus,  and  Compound  Rhubarb  powder,  Pulvis 
Rhei  Compositus,  are  examples.  If  there  be  much  flatulence,  or  if  you 
desire  to  give  a  little  stimulus  to  the  secretion  of  the  gastric  juice,  you 
may  add  to  the  pill  or  pills  half  a  grain  or  a  grain  of  Capsicum,  Capsici 
Fructus,  or  ordinary  Cayenne  Pepper,  with  advantage. 

You  must  recollect  in  administering  pills  not  to  order  more  than 
five,  or  at  the  most  six  grains  in  one  pill,  or  you  will  astonish  your 
patient  by  the  size  of  the  bolus  you  have  ordered  him  to  take.  Five 
grains  form  a  moderate-sized  pill,  but  if  blue  pill  or  calomel  should  be 
one  of  the  ingredients,  the  pill  will  be  small,  because  a  grain  of  these 
mercurial  preparations  occupies  very  little  space.  This  matter  of  the 
size  of  pills  must  be  borne  in  mind,  for  some  people  think  it  an  insult 
to  receive  a  large  pill,  and  many  will  tell  you  they  cannot  swallow  one 
of  even  moderate  size.  The  professed  inability  to  swallow  a  pill  is  often 


COMPOUND  LICORICE  POWDER.  137 

mere  affectation  or  determination  on  the  part  of  the  patient  not  to 
attempt  to  do  so ;  but  some  persons  have  a  real  difficulty.  For  them 
the  pill  may  be  silvered  or  gilt,  or  covered  with  a  tasteless  starch  coating, 
and  if  neither  of  these  plans  will  please,  tell  them  to  pack  the  pill  up  in 
a  small  piece  of  moistened  "  pastry-cooks'  paper,"  when  the  whole  will 
slip  down  whether  the  patient  will  swallow  it  or  not.  This  pastry-cooks' 
paper  can  now  be  obtained  at  many  of  the  large  chemists,  and  is  an 
excellent  thing  in  which  to  give  powders  to  children.  Little  capsules  of 
this  material  have  been  prepared  and  made  in  separate  halves.  The 
powder  or  pill  is  placed  in  one  and  the  cover  applied,  the  edges  being 
slightly  moistened,  the  two  halves  adhere,  and  the  little  parcel  with  the 
included  medicine  can  be  swallowed  without  any  difficulty. 

Nux  Vomica  is  another  remedy  which  may  be  given,  by  itself  or 
combined  with  a  purgative,  in  cases  of  imperfect  action  of  the  bowels. 
It  is  useful  by  giving  tone  to  the  bowel  and  stimulating,  probably  through 
its  action  on  the  nerves,  the  muscular  coat  of  the  intestine.  It  is  now 
frequently  prescribed.  It  comes  from  the  plant  which  yields  Strychnine, 
Strychnos  Nux  Vomica.  You  may  give  of  the  Extract  of  Nux  Vomica, 
Exlractum  Nucis  Vomicce,  from  a  quarter  of  a  grain  to  a  grain.  If  added 
to  a  purgative  pill,  it  helps  the  action  of  the  large  bowel.  The  Tincture 
of  Nux  Vomica,  Tinctura  Nucis  Vomica,  may  be  prescribed  in  doses  of 
from  five  to  twenty  minims  with  some  Compound  Tincture  of  Bark  or 
other  tonic.  Decoction  of  Aloes,  Decoctum  Aloes  Compositum,  Tincture 
of  Senna,  Tincture  of  Rhubarb,  are  simple  remedies  which  are  often 
prescribed  in  doses  of  from  a  drachm  to  half  an  ounce. 

Scammony,  Scammonium,  a  gum  resin  from  the  root  of  Convolvulus 
Scamrnonia,  is  a  component  of  many  purgative  pills,  and  is  a  very  active 
purgative.  For  children  suffering  from  intestinal  worms,  Scammony  is 
one  of  the  best  remedies.  It  may  be  given  in  doses  of  one  or  two 
grains,  or  from  three  to  five  grains  of  the  Compound  Scammony  Powder, 
Pulvis  Scammonice  Compositus,w\\\c\\  consists  of  Scammony,  4;  Jalap,  3 ; 
and  Ginger,  i,  may  be  ordered  instead  of  the  pure  drug.  It  may  be 
taken  in  a  little  milk.  Probably  many  patent  purgative  medicines  con- 
tain Scammony.  It  is  a  rather  searching  purgative,  which  clears  out  the 
bowel  well,  expelling  any  hardened  faeces  and  wind  that  may  have 
collected. 

Compound  Licorice  Powder  is  now  in  the  Pharmacopoeia.  The  pre- 
paration is  much  used  in  Germany  and  Russia,  and  is  certainly  one  of 
•the  best  and  safest  of  ordinary  purgative  medicines.  The  Pulvis  Glycyr- 
rhizcz  Compositus  of  the  British  Pharmacopoeia  contains  two  ounces  of 
finely  powdered  Senna  and  the  same  quantity  of  powdered  Licorice 
root,  with  six  ounces  of  powdered  sugar;  but  the  German  preparation, 
is  made  as  follows: — "Powdered  Senna,  powdered  Licorice,  of  each 
2;  powdered  Fennel,  Sulphur,  of  each  i;  white  sugar,  6:  mix." 

12* 


138  OF  THE   USE   OF  ALOES. 

The  dose  of  the  powder  is  a  teaspoonful,  carefully  mixed  in  a  little 
water. 

Aloes  is  another  purgative  which  has  the  property  of  acting  upon  the 
large  bowel.  It  probably  irritates  the  mucous  membrane,  and  excites 
its  glands  to  secrete ;  but  also,  by  reflex  nervous  action,  it  stimulates  the 
action  of  the  muscular  coat  of  the  intestine,  and  excites  vigorous  con- 
traction both  of  the  circular  and  longitudinal  muscular  fibres.  It  is  a 
very  good  purgative  to  give  in  cases  of  torpid  bowels,  but  it  is  important 
for  you  to  bear  in  mind  that  aloes  has  the  effect  in  some  cases  of 
encouraging  the  formation  or  increase  of  haemorrhoids  or  piles,  see  p.  120. 
It  seems  to  irritate  the  mucous  membrane  of  the  lower  bowel,  and  those 
who  suffer  from  an  irritable  state  of  this  part  sometimes  find  their 
sufferings  much  increased  if  they  take  any  of  the  ordinary  preparations 
of  Aloes.  There  is  the  Socotrine  Aloes,  Aloe  Socotrina,  and  Barbadoes 
Aloes,  Aloe  Barbadensis.  The  Compound  Decoction  of  Aloes,  Decoctum 
Aloes  Compositum,  is  ordered  to-  be  made  of  Socotrine  Aloes,  and 
contains  besides,  Myrrh,  Saffron,  Carbonate  of  Potash,  Licorice, 
Compound  Tincture  of  Cardamoms,  and  Distilled  Water.  This  is  a 
very  valuable  preparation,  a"nd  enters  into  the  composition  of  many 
favorite  draughts  which  used  to  be  prescribed  in  former  days,  and 
which  brought  gain  to  the  apothecaries  of  old.  That  once  very  fashion- 
able but  rather  nasty  dose  called  a  Black  Draught  was  composed  of 
Decoction  of  Aloes,  with  Sulphate  of  Magnesia,  Senna,  and  Licorice. 
Its  composition  was  modified  by  different  authorities,  and  some  im- 
provements, more  nasty  still,  were  made  by  ingenious  physicmongers ; 
but  the  reputation  of  the  black  draught  is  gone,  and,  though  an  excel- 
lent purgative,  it  is  seldom  prescribed  in  these  days.  Forty  years  ago 
Dr.  Chambers,  who  was  then  the  fashionable  physician  in  London,  and 
other  physicians  only  a  little  less  fashionable,  prescribed  blue  pills  and 
black  draughts  for  most  ailments.  It  would  not  be  easy  now  to  persuade 
people  to  swallow  a  black  draught.  However,  with  a  little  ingenuity 
you  may  make  something  less  nauseous  and  equally  efficacious.  The 
Decoction  itself  may  be  taken  in  doses  of  from  two  drachms  to  an 
ounce  and  a  half  or  more. 

Probably  the  best  preparation  of  aloes,  to  prescribe  in  the  form  of 
pills,  is  the  Watery  Extract  of  Aloes  {Extractum  Aloes  Socotrina).  This 
watery  extract  does  not  irritate  the  bowels,  and  acts  very  effectually.  It 
may  be  given  in  doses  varying  from  the  one-sixth  of  a  grain  up  to  a 
grain  or  more,  but  it  is  better  not  to  order  a  larger  dose  than  is  abso 
lutely  requisite,  and  in  prescribing,  it  is  well  to  bear  in  mind  that  Aloes, 
as  well  as  many  other  drugs,  have  their  purgative  action  much  improved 
.by  being  reduced  to  a  state  of  very  minute  division,  and  mixed  with 
other  things.  If  small  pieces  of  Aloes  should  stick  in  the  mucous 
membrane  of  the  large  bowel,  that  particular  part  might  be  severely 


OF  THE    USE    OF  PODOPHYLLIN.  139 

irritated,  and  in  consequence  the  patient  would  experience  great  pain 
and  discomfort ;  while,  if  the  medicine  was  very  minutely  divided  and 
mixed  with  a  quantity  of  inactive  or  less  active  material,  there  would 
be  no  danger  of  any  such  deleterious  action.  When  you  prescribe 
aloes,  you  should  always  order  it  to  be  intimately  mixed  with  other 
and  less  active  substances.  Let  the  pill  contain,  say,  a  quarter  of  a 
grain  of  the  Extractum  Aloes  Aquosum  with  two  or  three  grains  of 
common  Extract  of  Colocyrith  {Extractum  Colocynthidis  Compost  futri), 
and  a  grain  of  Extract  of  Henbane  {Extractum  Hyoscyami}.  Although 
in  these  days  it  is  the  fashion  to  prescribe  one  remedy  only,  and  I 
believe  some  distinguished  physicians  consider  it  improper  to  order 
more  than  two  drugs  in  one  pill  or  mixture,  there  is  not  the  least 
doubt  that,  as  far  as  regards  the  action  of  the  medicine  upon  the 
organism,  considerable  advantage  is  gained  by  mixing  several  remedies 
together.  Medicines,  like  foods,  affect  different  people  in  a  different 
v/ay.  If  you  prescribe  several  different  things  together,  you  may 
influence  different  idiosyncracies,  while  it  would  be  almost  impossible 
to  determine  the  particular  purgative  suitable  for  each  individual 
patient.  I  much  prefer  a  pill  consisting  of  a  little  Compound 
Colocynth,  a  little  Nux  Vomica,  a  little  Henbane,  a  small  quantity  of 
Podophyllin,  and  perhaps  a  little  of  the  Watery  Extract  of  Aloes,  to  a 
full  purgative  dose  of  any  one  of  these  preparations  by  itself.  By 
mixing  these  things  together,  you  get  a  less  painful  and  more  efficient 
action  than  you  do  from  a  large  dose  of  either  of  them  separately.  If 
you  desire  to  test  the  truth  of  this  observation,  you  may  carry  out  a  very 
instructive  experiment  on  your  own  organisms.  Take,  for  example,  one 
grain  of  Podophyllin  and  see  how  it  affects  you,  and  the  next  time  you 
require  a  purgative  take  three  grains  of  the  Watery  Extract  of  Aloes 
alone.  On  another  occasion  try  a  very  small  dose  (a  quarter  or  the 
third  of  a  grain)  of  Podophyllin  or  Aloes,  mixed  with  three  grains  of 
compound  Colocynth  pill,  and  notice  whether,  upon  the  whole,  you  do 
not  get  a  better  result  with  less  griping  pain  than  when  you  took  the 
larger  doses  of  the  simple  drugs. 

Podophyllin  has  been  much  used  during  the  last  ten  years,  and  was 
first  employed  in  America.  But  it  is  a  purgative  of  somewhat  uncertain 
action,  and  those  who  order  it  should  take  care  how  they  prescribe  it. 
I  remember  the  case  of  a  child  who  was  almost  killed  by  half  a  grain  of 
Podophyllin,  incautiously  ordered  by  the  practitioner,  who  perhaps  up 
to  that  time  had  been  employing  some  weak  and  inferior  preparation  ; 
but  this  last  prescription,  being  made  up  by  a  chemist  who  used  good 
medicines,  a  much  too  powerful  dose  was  administered.  The  drug 
varies  much  in  quality,  and  it  is,  moreover,  one  of  those  things  which 
acts  very  differently  upon  different  people.  I  have  patients  who  have 
been  taking  a  small  quantity  of  Podophyllin  for  many  years,  and  who 


I4O  DRASTIC  PURGATIVES. 

say  they  have  never  taken  anything  which  acts  so  satisfactorily.  On  the 
other  hand,  I  every  now  and  then  get  into  disgrace  for  ordering  the 
same  thing  to  other  persons.  The  drug  sometimes  gripes  the  patient  so 
much  that  he  does  not  wish  to  try  the  remedy  again.  You  should 
always  order  Podophyllin  first  in  small  doses,  mixed  with  compound 
Rhubarb 'or  compound  Colocynth  pill,  and  if  it  causes  no  discomfort, 
you  can  easily  increase  the  dose.  Do  not  give  more  than  one-quarter 
or  one-third  of  a  grain,  unless  you  know  by  experience  the  patient  can 
take  larger  doses  with  advantage. 

Drastic  and  Hydragogue  Purgatives  can  hardly  be  included  among 
the  remedies  for  slight  ailments,  but  a  few  of  them  may  be  prescribed  in 
small  doses  for  ordinary  maladies.  Thus  Jalap,  Jalapa,  is  a  very  old  and 
useful  purgative,  which  may  be  taken  in  doses  varying  from  five  to  fifteen 
grains.  It  excites  the  flow  of  fluid  from  the  blood  into  the  intestine,  and 
when  prescribed  should  be  mixed  with  an  equal  quantity  of  Bitartrate, 
Potasses  Tartras  Adda,  or  Sulphate  of  Potash,  Potassa  Sulphas. 

Jalapine  is  obtained  from  ordinary  jalap  by  rectified  spirit.  It  is  the 
resin,  in  fact,  Resina  Jalapa,  deprived  of  its  coloring  matter  by  animal 
charcoal.  A  small  dose  of  from  one  to  three  grains  will  be  found  to  act 
freely.  It  may  be  prescribed  in  a  pill  or  as  a  powder,  mixed  with  a 
few  grains  of  sugar. 

Elaterium,  Cretan- Oil,  Gamboge,  are  all  violent  purgatives,  which  are 
very  useful  in  the  treatment  of  some  diseases,  but  are  not  required  in 
the  management  of  slight  ailments.  They  should  all  be  prescribed  in 
very  small  doses  to  begin  with.  In  fact,  the  practitioner  who  uses  these 
drugs  should  always  ascertain  whether  the  patient  will  bear  them  by 
ordering  in  the  first  instance  a  very  small  dose.  Drastic  cathartics  all 
excite  the  pouring  out  of  a  large  quantity  of  fluid  from  the  blood  through 
the  walls  of  the  capillaries  into  the  bowel. 

In  this  place  I  ought  properly  to  speak  of  the  action  of  preparations 
of  Mercury,  but  as  this  subject  will  come  under  consideration  a  little 
further  on,  I  shall  postpone  what  I  have  to  say  for  the  present. 

Saline  Purgatives  are  very  valuable  in  many  cases  of  imperfect  action 
of  the  bowels.  Many  of  the  salts  used  as  purgatives  act  not  only  by  pro- 
moting osmose  of  fluid  from  the  blood  by  reason  of  the  higher  specific 
gravity  of  the  saline  solution  in  the  intestine  than  that  of  the  liquor 
sanguinis,  and  by  their  direct  influence  on  the  nerves  of  the  mucous 
membrane,  but  also  in  consequence  of  being  first  of  all  absorbed  into 
the  blood,  and  then  excreted  by  the  glands  and  follicles  of  the  mucous 
membrane  of  the  colon.  At  the  same  time  many  other  substances  are 
removed  from  the  blood  with  the  salt,  and  in  this  way  the  circulating 
fluid  may  be  freed  from  certain  deleterious  constituents  which  have 
accumulated  in  it,  and  which  if  they  remained  would  seriously  interfere 
with  the  action  and  nutrition  of  various  tissues  and  organs.  Most 


SULPHATES   OF  MAGNESIA   AND  SODA.  14! 

salines  act  partly  as  purgatives  and  partly  as  diuretics,  and  not  a  few 
of  them  have  the  effect  of  increasing  the  secretion  of  many,  if  not  of  all, 
of  the  glands  of  the  digestive  system. 

There  are  many  salts  in  the  Pharmacopoeia  which  you  will  find 
useful.  Some  of  these  are  very  ancient  remedies,  and  well  known  in 
all  countries.  First  of  all,  there  is  Epsom  Salts,  Sulphate  of  Magnesia, 
Magnesia  Sulphas,  and  a  capitaf  remedy  it  is.  It  forms,  as  it  were,  the 
basis  of  a  great  many  fashionable  medicines,  and  many  people  fre- 
quently take  it  without  knowing  from  what  a  common  drug  they  derive 
relief.  It  is  one  of  the  cheapest  of  medicines,  for  a  pound  of  it  only 
costs  a  few  pence.  It  may  be  given  in  doses  varying  from  half  a  drachm 
to  half  an  ounce  or  an  ounce,  in  solution  in  water.  The  small  dose, 
especially  if  dissolved  in  warm  or  lukewarm  water,  will  sometimes  purge 
freely  and  quickly.  As  a  medical  author  has  metaphorically  remarked 
concerning  a  much  advertised  water,  it  is  "speedy,  sure,  and  gentle!" 

Sulphate  of  magnesia  is  not  an  unpleasant  thing  to  take,  especially 
if  you  mix  it  with  about  one-fourth  of  its  weight  of  common  salt  and 
twenty  drops  of  Aromatic  Sulphuric  Acid  (Acidum  Sulphuricum  Aro- 
maticum),  the  whole  being  dissolved  in  an  ounce  and  a  half  of  lukewarm 
water.  I  often  order  ten  minims  of  dilute  Hydrochloric  Acid,  Acidum 
Hydrochloricum  dilutum,  and  two  drachms  of  Sulphate  of  Magnesia,  to 
be  dissolved  in  an  ounce  and  a  half  of  Cinnamon  Water,  Orange  Flower 
Water,  Aqua  Aurantii  Floris,  common  Water,  or  Infusion  of  Roses, 
Infusum  Rosa  Acidum.  The  last  gives  a  rather  pleasant  taste  and 
agreeable  color  to  the  draught,  which  should  be  taken  in  the  morning 
before  breakfast,  or  about  two  hours  after  that  meal.  If  you  consider  it 
desirable  to  act  upon  the  kidneys  at  the  same  time  as  the  bowels,  and 
often  it  is  very  important  so  to  do,  you  may  add  a  few  grains  of  Nitre, 
Pulvis  Potasses  Nitralis,  and  in  this  way  you  make  a  saline  draught 
which  many  of  your  patients  will  find  useful.  It  may  be  taken  day 
after  day  for  three  or  four  days,  or  twice  or  three  times  a  week ;  but  its 
daily  use  should  not  be  continued  for  longer  than  a  fortnight  at  a  time. 

Sulphate  of  Soda,  or  Glauber's  Salt,  Sodce  Sulphas  of  the  Pharma- 
copoeia, is  not  so  strong  in  its  purgative  action  as  the  Sulphate  of 
Magnesia,  but  it  is  not  nearly  so  disagreeable  in  taste.  You  may  give  two 
or  more-  drachms  of  Sulphate  of  Soda  dissolved  in  an  ounce  and  a  half 
of  water.  Or  you  may  prescribe  two  or  three  drachms  of  the  Sulphate  of 
Soda  with  a  somewhat  less  quantity  of  the  Sulphate  of  Magnesia  with  five 
or  ten  grains  of  Nitre  and  a  drachm  or  more  of  common  salt.  The  addi- 
tion of  common  salt  you  will  find  advantageous,  as  it  certainly  much 
diminishes  the  nauseous  taste  of  the  Sulphate  of  Magnesia.  Salines 
generally,  like  many  other  medicines,  act  more  powerfully  if  they  are  com- 
bined than  if  taken  separately,  and,  as  I  have  already  said,  their  action  is 
expedited  and  increased  if  they  are  dissolved  in  warm  or  lukewarm  water. 


142  FRIEDRICHSHALL    WATER. 

Phosphate  of  Soda,  Soda  Phosphas,  is  another  salt  which  acts  w'ell 
as  a  mild  purgative  in  doses  of  from  one  drachm  to  an  ounce  dissolved 
in  water.  It  is  not  disagreeable,  and  has  long  been  known  as  "  Taste- 
less Saline  Aperient."  It  is  a  good  saline  for  children,  and  maybe 
given  dissolved  in  weak  beef-tea  or  other  form  of  broth  or  soup. 

Soda  Tartarata,  a  Tartrate  of  Soda  and  Potash,  commonly  called 
Rochelle  Salt,  used  to  be  a  very  favorite  saline  purgative.  It  also 
acts  on  the  kidneys.  The  acid  of  this  salt,  like  Citric  and  many  other 
vegetable  acids,  becomes  changed  in  the  system,  alkaline  carbonates 
being  formed  which  render  the  urine  alkaline.  The  dose  is  from  one 
drachm  to  half  an  ounce  or  more  dissolved  in  water.  You  may  order  a 
mixture  containing  half  a  dozen  doses,  and  direct  the  patient  to  take 
an  ounce,  that  is,  two  tablespoonfuls,  with  one  tablespoonful  of  hot 
water.  If  the  dose  is  taken  before  breakfast,  it  will  generally  act  in  the 
course  of  two  or  three  hours,  and  many  a  patient  will  have  good  reason 
to  thank  you  for  the  advice  you  have  given  him. 

Many  such  saline  mixtures  may  be  used  instead  of  purgative  mineral 
waters.  Their  action  is  much  the  same,  but  you  will  find  that  not  a  few 
of  the  most  prosperous  of  your  patients  will  decline  to  take  such  salines 
as  you  can  prescribe.  They  require  a  more  fashionable  form  of  saline  in 
the  shape  of  a  purgative  mineral  water  from  some  wonderful  spring  war- 
ranted to  cure  all  diseases,  and  patronized  by  the  nobility  of  Europe. 
In  these  days  there  are,  indeed,  a  number  of  potent  natural  mineral 
waters  having  purgative  properties  from  which  to  choose.  A  few  years 
since,  almost  every  person  was  advised  to  take  Pullna  water.  This 
after  a  time,  like  the  once  famous  Epsom  and  Cheltenham  waters, 
gave  place  to  others.  For  years  Friedrichshall  has  been  credited  with 
virtues  of  surpassing  excellence,  but  now  I  suppose  opinion  is  divided 
between  this  and  the  unpronounceable  Hunyadi  Janos  bitter  water.  The 
latter  contains  much  more  of  the  purgative  sulphates  than  Pullna, 
Seidlitz,  Kissengen,  or  Friedrichshall,  and  therefore  acts  more  freely. 

Friedrichshall  water  is  a  mild  purgative  saline.  Its  composition  is 
shown  in  the  following  analysis,  for  which  I  am  indebted  to  Mr.  C.  H. 

ANALYSIS    OF    FRIEDRICHSHALL    BITfER   WATER. 

Grains  per  gallon. 

Sodium 657-5 

Potassium 6-l 

Magnesium 200-8 

Calcium 187 

Silica 1 7 

Chlorine .' 1003-1 

Bromine 0-13 

Sulphuric  acid  (S04) 739'2 

Carbonic  acid  not  estimated. 

Piesse,  Public  Analyst,  London.      It  seems  to  contain   Sulphate  of 
Magnesia  and  Chloride  of  Sodium. 


EFFERVESCING  SALINES.  l\$ 

Mr.  Piesse  remarks  that  if  the  "Chlorine"  be  calculated  into 
"Chloride  of  Sodium,"  and  the  "Magnesium"  into  "  Sulphate  of  Mag- 
nesia," and  the  amounts  of  the  salts  thus  indicated  be  dissolved  in  one 
gallon  of  ordinary  drinking  water,  we  shall  have  a  solution  very  like  the 
natural  Friedrichshall  water,  especially  if  the  mixture  be  well  charged 
with  carbonic  acid. 

You  may  tell  the  patient  to  take  a  wineglass  of  Friedrichshall  or 
Hunyadi  Janos  water  with  as  much  warm  water  every  morning  before 
breakfast,  and  in  many  cases  it  may  with  advantage  be  prescribed  with 
twice  as  much  Carlsbad  water  made  warm,  or  hot  water  added.  For 
patients  who  object  to  the  expense  of  mineral  waters  you  may  easily 
prescribe  a  substitute  according  to  the  principles  already  mentioned, 
page  141.  Whether  the  Sulphate  of  Magnesia  and  Sulphate  of  Soda  in 
the  water  obtained  from  a  spring  is  in  a  state  in  any  way  molecularly 
different  from  the  salts  as  sold  by  chemists  has  not  been  determined,  but 
certainly  the  less  wealthy  seem  to  derive  as  much  benefit  from  solutions 
of  ordinary  Sulphates  of  Magnesia  and  Soda,  as  the  rich  do  from  purga- 
tive mineral  waters. 

Sulphate  of  Potash,  Potassa  Sulphas,  is  a  very  old  saline  aperient. 
It  may  be  taken  in  doses  of  from  ten  grains  to  three  scruples  dissolved 
in  water.  It  enters  into  the  composition  of  many  of  our  remedies  in 
the  Pharmacopoeia. 

Effervescing  Saline  purgative. — But  perhaps  the  pleasantest  saline 
purgative  is  an  effervescing  draught.  We  have  an  excellent  mild  purga- 
tive in  what  is  now  called  Granular  Citrate  of  Magnesia.  I  believe 
that  much  of  what  is  sold  under  this  name  is  really  Citrate  of  Potash  or 
Soda.  The  ingredients  are  mixed,  and  the  water  of  crystallization  in 
part  driven  off  by  heat,  but  the  preparation  is  a  difficult  one  to  make 
well.  The  dose  is  from  one  to  two  teaspoonfuls  thrown  into  a  tumbler 
two-thirds  full  of  water,  and  the  mixture  is  to  be  taken  during  effer- 
vescence. The  granulated  salts  must  be  carefully  excluded  from  damp, 
but  if  this  be  done  they  keep  for  a  long  period  of  time.  Such  effer- 
vescing draughts  are  very  agreeable  in  hot  climates.  It  is  of  course 
only  a  very  mild  form  of  purgative,  but  useful  in  a  great  many  cases 
when  a  cooling  saline  is  required.  The  urine  is  rendered  alkaline  by 
the  salt. 

.Many  different  forms  of  granulated  effervescing  salts  are  now  pre- 
pared by  chemists,  containing  Quinine,  Strychnine,  Pepsine,  Bismuth, 
Lithia,  and  many  other  substances.  Granulated  Effervescing  Salts 
also  constitute  a  very  agreeable  vehicle  for  many  different  kinds  of 
medicine. 

In  giving  purgatives,  do  not  forget  that  it  is  a  great  point  to  hit 
the  exact  time,  for  a  very  moderate  dose  will  often  produce  a  full  and 
sufficient  effect,  although  at  another  time,  in  the  case  of  the  very  same 


144  DIARRHCEA. 

person,  a  larger  dose  will  have  little  or  no  effect,  save  causing  severe 
pain.  If  the  right  time  can  be  selected,  a  mild  purgative  will  be  of  the 
greatest  use,  and  may  possibly  have  the  effect  of  preventing  an  attack 
of  illness.  This  variability  in  the  action  of  the  same  medicine  Is  very 
remarkable  in  the  case  of  mercury,  an  extremely  small  quantity  of 
which  has  sometimes  the  most  beneficial  effect  in  dissipating  symptoms 
which  for  several  days  may  have  indicated  serious  general  disturbance 
and  the  derangement  of  more  than  one  important  organ  of  the  body. 

DIARRHCEA. 

I  pass  now  to  the  consideration  of  a  condition  the  very  opposite  of 
constipation.  Diarrhoea  (&a,  through,  P«J,  I  flow),  though  a  common 
ailment,  is  less  frequent  than  constipation,  and  is  seldom  habitual  and 
persistent,  lasting  perhaps  for  the  greater  part  of  a  lifetime,  like  the 
tendency  to  constipation.  Now  and  then,  however,  you  do  meet  with 
people  who  seem  to  surfer  very  frequently  from  a  condition  to  which 
the  term  diarrhoea  would  be  generally  applied.  To  your  inquiry  if  the 
bowels  are  open  the  patient  will  perhaps  reply  "Too  much  so."  On 
further  questioning,  you  find  that  the  bowels  act  three  or  four  times 
every  day.  In  some  of  these  cases  the  patients  do  not  appear  to  surfer 
pain,  nor  do  they  necessarily  get  thin  and  weak,  or  appear  to  be  out 
of  health.  Whether  the  looseness  depends  upon  a  highly  irritable 
state  of  the  nerves  of  the  mucous  membrane,  or  is  due  to  weak  vascular 
walls,  or  to  an  altered  state  of  the  blood,  or  to  a  highly  nervous  dis- 
position, it  is  often  difficult  to  decide.  In  some  cases  the  condition 
results  from  a  peculiar  habit  of  body,  and  undoubtedly  there  are  types 
of  constitution  which  are  remarkable  for  the  great  activity  of  various 
secreting  glands,  just  as  there  are  others  as  remarkable  for  slow  ai>i 
imperfect  action.  In  neither  case  is  there  any  structural  alteration  :  but 
one  class  is  characterized  by  rapid,  the  other  by  sluggish,  change. 

That  diarrhoea  may  be  produced  through  nerve  influence  only,  is 
proved  by  a  number  of  circumstances.  Many  nervous  people  are  very 
subject  to  it.  Fright,  anxiety,  and  sudden  joy  may  be  immediately 
followed  by  diarrhoea.  Many  students  who  have  been  exceedingly 
anxious  concerning  examinations,  have  experienced  the  influence  of 
the  mind  acting  through  the  nervous  system  upon  the  secreting  glands 
which  discharge  their  contents  into  the  intestinal  canal.  The  action  is 
due  mainly  to  a  relaxation  of  the  muscular  fibres  of  the  small  vessels, 
permitting  dilatation  and  a  free  discharge  of  fluid  from  the  blood  directly 
into  the  bowels,  as  well  as  indirectly  into  the  secreting  glands. 

To  those  who  surfer  from  constipation,  an  occasional  attack  of 
diarrhoea  is  very  advantageous,  and  is  not  to  be  regretted.  Probably 
diarrhoea  carries  off  many  noxious  materials  that  have  accumulated  in 
the  blood,  and  may  therefore  be  beneficial  to  some  organisms,  provided 


CHANGES  IN  DIARRH(EA.  145 

it  only  occurs  now  and  then,  and  does  not  last  for  too  long  a  time,  and 
is  not  allowed  to  become  very  severe  at  a  time  when  there  happens  to  be 
an  epidemic.  But  you  must  not  forget  that  an  attack  of  typhoid  fever  is 
often  ushered  in  by  slight  and  sometimes  by  severe  diarrhoea.  There  is 
usually  a  very  decided  rise  in  temperature,  which  in  many  cases  will  en- 
able you  to  form  an  opinion  as  to  the  nature  of  the  malady. 

There  are  times  when  diarrhoea  must  be  guarded  against,  and,  if  it 
occurs,  must  not  be  allowed  to  persist.  During  an  epidemic  of  cholera, 
a  person  suffering  from  diarrhoea  must  be  very  carefully  watched,  for,  if 
the  condition  continue  unchecked  for  even  a  short  time,  it  may  become 
choleraic.  In  cholera-times  what  appears  to  be  ordinary  diarrhoea  may 
be  succeeded  in  the  course  of  a  few  hours  by  the  collapse  stage  of  chol- 
era. The  disease  usually  begins  with  slight  purgation,  and  you  cannot 
tell  whether  a  person  is  going  to  have  a  mild  attack  of  ordinary  diarrhoea 
or  actual  cholera.  It  therefore  behooves  us  to  be  on  our  guard,  and,  dur- 
ing the  prevalence  of  a  cholera  epidemic,  it  is  important  to  at  once  check 
all  cases  of  diarrhoea. 

The  commonest  form  of  diarrhoea  is  that  which  we  meet  with  in  hot 
summers,  and  often  prevails  to  a  great  extent  in  autumn.'  This  is  often 
called  summer  diarrhoea,  and  it  is  hard  to  say  exactly  what  occasions  it. 
Certain  it  is  that  it  is  more  prevalent  in  hot,  dry  summers,  than  it  is  in 
cold,  wet  ones.  Some  would  explain  the  fact  by  the  superabundance 
and  cheapness  of  fruit  in  the  former,  and  its  scarcity  and  high  price  in 
the  latter.  Plums  usually  get  the  credit  of  exciting  diarrhoea,  but  the 
condition  frequently  shows  itself  before  plums  are  obtainable.  No  doubt 
bad,  unripe  fruit,  and  decaying  fruit  are  very  liable  to  irritate  the  bow- 
els, and  may  excite  diarrhoea.  Neither  is  there  any  doubt  that  decom- 
posing vegetable  and  animal  matter  will  bring  on  an  attack  of  diarrhoea; 
but  what  the  particular  organic  material  may  be  which  exerts  the  dele- 
terious influence,  I  do  not  know.  On  the  other  hand,  it  is  quite  certain 
that  many  of  us  can  eat  very  considerable  quantities  of  any  ordinary  fruit 
without  suffering  in  any  way,  and  even  without  the. ordinary  half-consti- 
pated habit  being  relieved.  In  summer,  the  intestinal  canal  of  many- 
persons  seems  to  be  in  an  unusually  sensitive  or  irritable  state,  so  that 
very  slight  errors  in  diet  are  apt  to  derange  its  action  for  a  time.  Even 
a  little  beer  that  is  out  of  order,  or  sour  milk,  will  sometimes  set  up  a 
very  troublesome  attack  of  diarrhoea,  which  may  last  for  days,  and  re- 
quire careful  treatment  to  check  it. 

Concerning  the  precise  changes  which  occur  in  severe  diarrhoea,  little 
is  positively  known.  It  is  generally  supposed,  as  I  have  already  remarked, 
that  much  of  the  fluid  escapes  from  the  capillary  vessels;  but  at  least,  in 
some  cases,  it  is  more  probable  that  the  condition  depends  upon  increased 
activity  of  many  of  the  glands  which  discharge  their  contents  into  the 
intestinal  canal.  In  sudden  diarrhoea,  depending  upon  the  presence  of 
some  irritating  material,  I  suppose  transudation  of  fluid  takes  place  from 
13  K 


146  IRRITATIVE  DIARRHCEA. 

the  vessels,  as  well  as  increased  secretion  from  the  glands.  In  many 
cases,  for  some  time  before  the  attack,  it  is  probable  that  the  blood  has 
been  in  an  unhealthy  state,  in  which  case  the  free  discharge  of  watery 
matter  will  be  of  advantage  to  the  patient,  inasmuch  as  various  noxious 
materials  will  be  eliminated,  which  would  do  harm  if  they  were  retained 
in  it  in  a  state  of  solution.  Thus  by  the  attack  of  diarrhoea  is  the  blood 
depurated,  and  may,  in  this  way,  be  soon  restored  to  its  normal  healthy 
state.  Unquestionably,  therefore,  in  such  a  case,  diarrhoea  may  be  re- 
garded as  conservative  and  advantageous. 

Suppose  a  child  has  been  eating  a  quantity  of  unripe  fruit, — and  it  is 
nothing  very  unusual  for  an  English  baby  to  eat  half  a  dozen  unripe  and 
very  uninviting  looking  apples, — this  will  soon  ^produce  an  effect,  the 
stomach  and  bowels  will  be  irritated,  and  a  sudden,  and  it  may  be,  vio- 
lent derangement  will  follow,  often  accompanied  by  feverishness,  the 
temperature  in  such  cases  not  unfrequently  rising  to  103°  or  104°,  with 
perhaps  violent  abdominal  pain;  and  these  symptoms  maybe  sufficiently 
severe  to  excite  alarm.  If  vomiting  occurs  relief  is  at  once  experienced, 
but  more  commonly  purgation  is  excited,  and  may  perhaps  have  existed 
for  a  few  days  before  you  are  called  in  to  see  the  patient.  You  must  not 
expect  the  diarrhoea  to  cease  until  the  whole  of  the  irritating  matter  which 
excited  it  has  been  removed,  and  the  sooner  this  result  can  be  effected 
the  sooner  will  relief  be  afforded.  All  the  particles  of  half-masticated 
apples  containing  immature  acids  and  other  irritating  organic  compounds 
must  be  removed  from  the  alimentary  canal  before  the  diarrhoea  will  cease. 
In  such  cases,  therefore,  it  is  bad  practice  to  attempt  to  check  the  diar- 
rhoea unless  you  feel  sure  that  the  whole  of  the  irritating  substances  have 
been  entirely  got  rid  of.  It  is  even  desirable  to  encourage  for  a  time  the 
flow  of  fluid  from  the  intestinal  canal,  so  that  the  noxious 'matters  may 
be  thoroughly  washed  away.  For  this  reason  you  will  often  have  to  ad- 
minister a  mild  purgative  to  expedite  the  removal  of  the  matter  which 
excited  the  purgation.  You  purge  to  stop  purgative  action,  and  you  will 
often  find  this  the  best  and  shortest  method  of  checking  the  diarrhoea  of 
children.  Of  all  the  purgatives  that  are  known  to  remove  irritating  matters 
from  the  intestinal  canal,  oily  purgatives  are  the  most  suitable.  Common 
Olive-oil,  Oleum  Olivce,  will  act  in  this  way,  and  for  very  young  children 
is  quite  sufficient,  but  as  a  general  rule  you  will  find  it  expedient  to  give 
Castor-oil,  Oleum  Ricini,  the  purgative  action  of  which  is  more  decided. 
There  is  an  active  principle  in  the  Castor-oil  which  affects  the  action  of 
the  stomach  as  well,  as  the  glands  and  vessels  of  the  upper  part  of  the 
alimentary  canal.  In  this  way;  Castor-oil  in  its  action  contrasts  with 
Aloes,  Colocynth,  and  Sulphate  of  Magnesia,  which  act  mainly  upon  the 
lower  part  of  the  small  intestines  and  the  colon.  I  suppose  Castor-oil  ex- 
cites increased  secretion  in  the  stomach,  the  duodenum,  the  jejunum,  and 
ileum,  causing  a  quantity  of  fluid  to  be  quickly  poured  out  from  the  vessels 
and  glands  of  the  mucous  membrane.  Thus  the  alimentary  canal  is  thor- 


CASTOR-OIL   IN  DIARRHCEA.  147 

oughly  flushed  in  every  part;  and  the  action  takes  place  from  above  down- 
wards. Any  irritating  matters  that  may  be  present  are  thus  swept  away. 
For  this  reason,  and  for  the  further  reason  that  Castor-oil  is  a  substance 
which  does  not  irritate  the  mucous  membrane  in  any  undue  or  uncom- 
fortable way,  it  is  the  best  purgative  to  give  in  any  cases  in  which  you 
have  reason  to  attribute  the  diarrhoea  to  injudicious  eating.  Particularly 
in  the  diarrhoea  of  infants  and  young  children  is  Olive-oil  or  Castor-oil 
a  safe  remedy.  As  a  general  rule,  you  will  find  a  much  smaller  dose  of 
Castor-oil  will  act  than  is  usually  administered.  To  a  child  of  ten  years 
old  you  may  give  half  a  teaspoonful  or  a  teaspoonful ;  to  an  adult,  two 
teaspoonfuls,  but  a  single  teaspoonful  of  Castor-oil  will  be  sufficient  for 
many  people.  The  objection  to  Castor-oil  is  its  nauseating,  disagreeable 
flavor.  I  have  already  referred  to  the  best  way  of  taking  it,  and  have 
offered  some  suggestions  for  disguising  the  taste.  See  p.  135. 

After  diarrhoea  has  continued  for  some  time,  there  may  be  a  good 
deal  of  severe  griping  pain  all  over  the  stomach,  or  at  least  in  its  upper 
part.  At  the  same  time  the  patient  feels  chilly  or  very  cold,  and  may 
actually  shiver;  very  generally  there  is  more  or  less  flatulence,  with  acid 
eructations,  loss  of  appetite,  and  occasionally  distressing  nausea.  The 
tongue  is  usually  furred,  and  there  may  be  a  nasty  taste  in  the  mouth, 
or  the  mouth  may  feel  clammy  and  disagreeable.  After  diarrhoea  has 
lasted  for  several  days,  there  may  be  considerable  depression  of  the 
heart's  action ;  and  not  unfrequently  severe  cramp  in  various  muscles 
increase  the  distress. 

Acid  eructations  and  the  rising  of  acid  fluid  into  the  mouth  will  be 
relieved  by  the  administration  of  alkalies  and  other  so-called  antacid 
remedies.  You  may  give  alkalies,  such  as  Potash,  Liquor  Potassa, 
twenty  drops  in  a  wineglass  full  of  water  once  in  three  or  four  hours, 
or  the  Bicarbonate  of  Potash  or  Soda.  Preparations  of  Bismuth  are  also 
useful,  as  the  Carbonate  of  Bismuth  (Bismuthi  Carbonas),  or  the  Nitrate, 
the  old  Trisnitrate  of  Bismuth  {Bismuthi  Nitras],  from  ten  to  twenty 
grains  for  a  dose,  suspended  in  water  with  the  help  of  a  little  mucilage, 
or,  better,  prepared  chalk  {Creta prceparata),  or  precipitated  chalk  (Cal- 
ais Carbonas  precipitata).  •  But  one  of  the  best  as  well  as  simplest  reme- 
dies to  give  in  these  cases,  and  particularly  in  gastric  and  intestinal  de- 
rangements occurring  in  infants  and  very  young  children,  is  Lime  Water 
{Liquor  Calcis}.  This  is  an  extremely  valuable  remedy,  which  is  not 
used  as  much  as  it  deserves  to  be.  Infants  are  very  subject  to  diarrhoea, 
and  I  fear  that  many  a  child  has  been  lost  simply  from  allowing  diar- 
rhoea to  continue,  which  would  have  been  easily  checked,  if  sufficiently 
early  in  the  attack  a  few  teaspoonful  doses  of  Lime  Water  in  milk,  or 
sweetened  Lime  Water  {Liquor  Calcis  Saccharatus],  had  been  given. 
Anything  of  an  irritating  character  will  very  soon  disorder  the  delicate 
mucous  membrane  of  the  intestinal  canal  of  an  infant,  and  a  very  simple 
remedy  administered  at  the  proper  time  will  stop  it,  but  if  the  purging 


148  TREATMENT  OF  DIARRHCEA. 

be  severe,  and  it  be  allowed  to  continue  for  a  few  hours,  extreme  exhaus- 
tion may  ensue,  and  be  soon  followed  by  death.  In  these  cases,  mothers 
often  make  the  unfortunate  mistake  of  feeding  the  child  too  much. 
Fearing  lest  it  should  be  starved,  they  keep  pouring  in  milk.  The 
secretions,  already  out  of  order,  get  worse,  and  the  milk,  instead  of 
being  properly  digested  and  assimilated,  is  either  rejected  in  the  form 
of  curd,  or  the  curd  formed  is  passed  onwards  into  the  small  intestine, 
where  it  excites  irritation  without  being  taken  up  and  absorbed.  Coagu- 
lation of  the  caseine,  without  subsequent  solution,  may  persist  perhaps 
for  many  days,  sometimes  for  a  week  or  more,  each  new  portion  of  milk 
that  is  swallowed  undergoing  the  same  change.  Thus  the  intestinal 
canal,  in  every  part  of  its  course,  becomes  filled  with  firm  white  coagula, 
which,  it  will  be  noticed,  constitute  the  greater  part  of  every  evacuation. 
After  death  from  violent  diarrhoea  it  is  not  uncommon  to  find  the  intes- 
tines even  distended  with  coagulated  and  undigested  curd. 

Cases  of  diarrhoea  in  infants  may  often  be  relieved  at  the  outset  by 
small  doses  of  Lime  Water.  A  little  may  be  mixed  with  the  milk,  in 
the  proportion  of  a  tablespoonful  or  less  of  lime  water  to  half  a  pint  of 
milk.  Sometimes  Potash  Water  answers  better,  and  I  have  used  Liquor  Po- 
tassae,  in  the  proportion  of  twenty  drops  to  half  a  pint  of  milk.  You  must 
not  allow  the  child  to  take  as  much  milk  as  it  likes.  For  a  day  or  two, 
half  a  pint  of  milk  in  the  twenty-four  hours  will  be  sufficient.  It  must 
be  obvious  that,  as  long  as  the  disturbed  state  of  the  bowels  continues, 
it  will  be  worse  than  useless  to  push  food.  Time  must  be  allowed  for 
the  alimentary  canal  to  become  partially  emptied  of  its  irritating  con- 
tents before  fresh  nourishment  is  introduced.  If  the  child  is  at  all  low, 
it  must  be  supported  with  small  doses  of  brandy — from  ten  to  twenty 
drops  in  a  teaspoonful  of  water  or  milk  and  a  little  sugar,' once  in  two 
hours.  You  cannot  be  too  careful  in  watching  cases  of  infantile  diar- 
rhoea, especially  in  weak  children,  for  it  sometimes  happens  that  serious 
exhaustion  comes  on  quite  unexpectedly,  and  if  you  do  not  visit  the 
patient  every  few  hours,  a  sudden  change  may  occur,  and  the  case  be 
hopeless  before  you  come  to  its  assistance. 

I  have  already  drawn  your  attention  to  the  fact  that  in  these  cases  of 
diarrhoea,  bacteria  often  grow  and  multiply  to  an  enormous  extent  in  the 
caseine  clots.  In  many  cases  every  part  of  the  intestinal  canal  is  per- 
vaded by  millions  of  these  organisms,  which  grow  and  multiply  in  the 
altered  secretions  and  food  which  are  continually  being  poured  into  the 
stomach.  The  changes  which  ought  to  take  place  in  the  food  prior  to 
its  absorption  and  conversion  into  healthy  blood  are  consequently  pre- 
vented. Children  may,  under  these  circumstances,  die  of  inanition, 
although  they  have  been  but  too  liberally  fed  during  the  whole  period 
of  the  illness.  The  food  they  are  plied  with  merely  serves  to  encourage 
the  growth  of  bacteria,  and  it  actually  undergoes  changes  which  interfere 
with  its  digestion  and  absorption.  If  just  at  the  right  time  you  withhold 


CHARACTERS   OF  THE  STOOLS.  149 

food,  perhaps  only  for  a  few  hours,  everything  may  right  itself;  the  irri. 
tating  matters  may  themselves  act  a  little  on  the  bowels,  and  thus  get 
pushed  onwards  by  the  contraction  of  the  muscular  coat  of  the  intestine. 
Diarrhoea  may  come  on  and  last  for  a  few  hours  or  so,  or  even  for  a  day 
or  two,  and  then  the  secretions  return  to  their  natural  state.  The  child 
will  be  out  of  danger  and  soon  be  well  again.  In  treating  diarrhoea  in 
children,  particularly  infants,  you  must  take  care  that  the  child  is  kept 
warm.  One  of  the  principal  causes  of  diarrhoea  is  cold,  and  bathing  in 
cold  water,  and  exposure  to  cold  and  wet  will  sometimes  bring  on  diar- 
rhoea even  in  adults. 

You  should  be  aware  of  the  different  characters  of  the  stools  in  different 
forms  of  diarrhoea.  If  they  are  of  the  natural  color  and  odor,  you  may 
let  the  diarrhoea  go  on  for  a  while,  for  it  will  probably  do  no  harm,  and 
will  most  likely  stop  without  medicinal  treatment.  But  if  the  stools 
should  become  much  altered — if  they  should  emit  a  sour  smell,  and  the 
secretion  should  have  the  appearance  of  rice  water,  it  will  probably  be 
necessary  to  check  the  discharge.  For  such  evacuations,  as  well  as  those 
which  are  colorless  or  almost  colorless,  consist  wholly,  or  in  great  part, 
of  secretions  poured  out  from  the  glands,  and  from  the  vessels  of  the 
mucous  membrane  of  the  lower  part  of  the  small  and  of  the  large  intestine. 
You  will  find  in  such  evacuations  much  altered  mucus,  with  numerous 
small  cells  (bioplasts)  from  the  follicles  as  well  as  from  the  surface  of  the 
mucous  membrane,  chiefly  of  the  colon.  Not  unfrequently  you  will  find 
a  little  blood  ;  but  there  may  be  more  albumen  than  the  quantity  of 
blood  will  account  for.  If  the  increased  formation  of  mucus  continue 
for  a  considerable  period  of  time,  it  is  often  associated  with  a  serious 
change  in  the  tissues  of  the  mucous  membrane  itself.  After  such  exces- 
sive action  has  gone  on  for  several  days  or  weeks,  there  may  ensue  an 
excoriated  and  almost  lacerated  state  of  a  small  portion  of  the  surface 
of  the  mucous  membrane.  A  sort  of  superficial  ulcer  results,  from  the 
surface  of  which  perhaps  blood  will  from  time  to  time  escape.  By  the 
continual  drain  of  nutrient  matter,  and  general  disturbance  of  the  action 
of  the  bowel,  a  low  state  of  health  may  soon  be  induced,  which,  with 
the  local  affection,  may  soon  lead  to  the  development  of  a  very  serious 
disease,  not  uncommon  in  many  tropical  climates,  but,  happily,  rarely 
contracted  here.  The  malady  in  question  is  Dysentery,  but  it  cannot 
be  included  among  "slight  ailments." 

Not  unfrequently,  however,  in  this  climate  the  colon  is  the  seat  of 
great  uneasiness,  often  amounting  to  actual  pain.  In  many  of  these 
cases  it  is  unquestionably  the  mucous  membrane  which  is  affected.  The 
capillaries  of  a  limited  area  become  congested.  The  congestion  not 
unfrequently  passes  into  ulceration,  and  we  have  an  approach  to  that 
state  of  things  which  may,  under  certain  circumstances,  be  soon  followed 
by  dysenteric  symptoms.  More  commonly,  if  proper  precautions  be 
taken,  the  patient  gets  better  before  actual  ulceration  occurs.  If  we 
13* 


150  DIET  IN  DIARRIKEA. 

could  see  the  mucous  membrane  in  some  of  these  cases,  I  have  no  doubt 
we  should  find  it,  in  the  immediate  situation  of  the  painful  spot,  swollen, 
red,  and  exceedingly  sensitive.  Every  time  the  muscular  coat  contracts, 
the  dull  pain  changes  in  character  and  becomes  severe.  The  affection 
may  occur  in  any  part  of  the  colon ;  but  I  think  the  sigmoid  flexure,  the 
caecum,  and  one  or  other  end  of  the  transverse  colon,  are  the  situations 
to  which  the  pain  is  usually  referred ;  and,  as  regards  frequency,  in  the 
order  in  which  I  have  named  them.  If  small  pieces  of  hardened  faeces 
or  the  debris  of  food  happen  to  be  forced  into  contact  with  the  spot, 
sudden  attacks  of  exquisite  pain,  of  a  cutting  or  tearing  character,  may 
be  experienced. 

Not  unusually  the  state  of  mucous  membrane  I  have  described  persists 
for  a  considerable  period  of  time.  This  condition  may  last  for  weeks, 
or  even  months,  just  as  a  portion  of  skin  may  be  deranged  by  congested 
ves'sels,  and  chronic  changes  induced  in  the  epithelium,  and  continue 
for  a  long  period.  Such  morbid  changes  may  be  stopped  by  judicious 
interference,  but  they  may  not  yield  to  remedial  measures  for  some  time. 
In  the  case  of  the  colon,  it  is  of  the  first  importance  not  to  allow  anything 
of  an  irritating  nature  to  pass  along  it — to  restrain  its  action  as  far  as 
possible — and  to  prevent  the  formation  of  wind,  and  the  consequent 
irregular  contraction  of  the  muscular  coat. 

In  some  forms  of  diarrhoea,  which  are  often  spoken  of  as  "bilious," 
you  will  notice  a  very  peculiar  alteration  in  the  character  of  the  stools, 
which  are  very  dark  colored,  and  not  unfrequently  may  be  fairly  spoken 
of  as  black.  Sometimes  the  color  is  such  as  to  suggest  the  idea  that  bile 
has  passed  down  the  intestine  without  undergoing  the  usual  changes,  and 
forms  the  chief  constituent  of  the  faeces.  In  some  of  these  cases  it  is 
probable  that  bile  accumulates  for  a  considerable  period  in  the  gall 
bladder,  until  at  last  this  viscus,  having  become  considerably  distended, 
suddenly  expels  its  contents,  which  are  discharged  in  such  considerable 
quantity  that  much  passes  almost  unchanged  into  the  large  bowel. 

You  must  be  careful  not  to  mistake  the  color  of  the  motions,  which 
is  produced  by  many  preparations  of  iron  for  that  caused  by  blood.  If 
a  person  takes  iron  his  motions  will  become  almost  black,  owing  to  the 
action  of  the  sulphuretted  hydrogen  of  the  alimentary  canal  producing  a 
dark  black  compound  with  iron.  Salts  of  bismuth  and  lead  also  impart 
to  discharges  from  the  bowel  a  very  peculiar  dark  color.  It  is  important 
to  distinguish  all  these  changes  from  those  caused  by  the  presence  of 
blood,  which  is  itself  much  changed  in  color  by  the  action  of  the  intes- 
tinal gases  and  fluids  which  act  upon  it. 

The  diet  is  of  the  greatest  importance  in  the  management  of  all  forms 
cf  diarrhoea.  Little  liquid  should  be  swallowed  while  the  purgation 
continues,  and  everything  taken  should  for  the  time  be  tepid  or  cold, 
for  hot  things,  and  particularly  hot  liquids,  seem  to  keep  up  the  diarrhoea. 
Ordinary  diet  must  be  withheld  for  a  time.  The  patient  may  live  upon 


ASTRINGENTS.  1 5 1 

milk,  thickened  or  not  with  flour,  Indian  corn,  or  lentil  flour,  arrow-root, 
sago,  tapioca,  or  other  bland,  non-irritating  starchy  matter.  Cream, 
puddings  made  with  eggs,  such  as  boiled  batter,  may  be  allowed,  but  any- 
thing containing  hard  particles  that  might  get  embedded  in  the  mucous 
membrane,  or  irritate  any  tender  spot  that  may  exist,  must  be  avoided. 

Treatment  of  Diarrhoea. — In  all  forms  of  diarrhoea,  particularly  where 
there  is  much  abdominal  pain,  it  will  greatly  contribute  to  the  comfort 
and  relief  of  the  patient  if  you  at  once  apply  warmth  to  the  external 
surface,  and  recommend  that  he  be  kept  in  a  warm  room.  He  should 
lie  down  and  rest,  and  if  the  attack  be  severe,  he  should  be  in  bed. 
Cold  unquestionably  fends  to  keep  up  diarrhoea,  and  may  in  fact  cause 
it.  Cold  also  increases  the  sufferings  of  the  patient.  Hot  fomentations 
to  the  stomach  have  been  strongly  recommended,  and  certainly  afford 
relief.  Various  plans  may  be  adopted.  One  of  the  simplest  is  to  wring 
flannels  out  in  very  hot  water,  and  have  them  quickly  applied ;  or  two 
or  three  thicknesses  of  dry  flannel,  held  before  a  good  fire  until  it  is 
quite  hot,  may  be  preferred.  The  wet  or  dry  flannels  should  be  covered 
with  a  piece  of  oiled  silk  or  mackintosh,  which  will  prevent  rapid  cool- 
ing ;  or  a  large  piece  of  spongio-piline,  made  moist  with  hot  water,  may 
be  applied.  A  better  plan  is  to  procure,  at  one  of  the  shops  where  India- 
rubber  things  are  sold,  a  hot-water  bottle,  made  of  good  strong  vulcan- 
ized India-rubber.  It  should  be  eight  or  nine  inches  by  fifteen,,  and 
covered  with  woollen  material.  In  cases  even  of  very  severe  griping 
pains,  great  relief  will  be  afforded  if  the  bottle  containing  hot  water  be 
placed  closed  to  the  skin  of  the  abdomen  while  the  patient  is  lying  on 
his  side,  and  kept  there  for  an  hour  or  more.  Those  who  are  subject  to 
troublesome  attacks  of  diarrhoea  should  wear,  during  winter  and  sum- 
mer, a  good  thick  flannel  belt  made  for  the  purpose. 

There  are  many  potent  remedies  for  checking  diarrhoea.  We  have 
alkalies,  the  action  of  which  I  have  already  referred  to ;  then  there  are 
many  astringents,  certain  metallic  salts,  acids,  and  sedatives.  Astringents 
(astringo,  to  bind)  are  often  given  in  diarrhoea,  and  unquestionably  check 
it.  Amongst  these  maybe  mentioned  "Krameria"  "Kino,"  "Catechu" 
"Logwood,"  and  several  more  are  in  general  use.  The  value  of  many 
astringent  remedies  used  in  diarrhoea  is  perhaps,  in  great  measure,  due 
to  the  Tannin  they  contain,  and  this  substance  itself  may  be  prescribed. 
It  is  a  powerful  astringent,  and  prevents  free  transudation  of  fluid  through 
the  walls  of  the  vessels.  The  precise  action  of  the  Tannin  is  not  fully 
understood.  It  may  act  directly  upon  the  tissues  themselves,  and  per- 
haps alter  the  permeable  or  diffusible  property  of  the  fluids.  At  the  same 
time  no  doubt  it  acts  upon  the  afferent  nerves  distributed  to  the  capil- 
laries, and  through  these  causes  contraction  of  the  muscular  fibres  of  the 
small  arteries.  Thus  their  calibre  is  reduced,  and  the  quantity  of  blood 
flowing  to  the  capillaries  lessened.  Logwood,  Hamatoxylon,  is  much 
used  in  the  treatment  of  ordinary  diarrhoea.  You  may  order  the  decoc- 


152  INTESTINAL    WORMS. 

tion  of  Logwood,  Decoctum  Hcematoxyli,  in  doses  varying  according  to 
the  severity  of  the  illness.  You  may  begin  with  small  doses,  say  from 
two  drachms  to  half  an  ounce  of  the  decoction  once  in  three  hours,  and 
if  the  diarrhoea  continues  the  dose  should  be  increased  to  an  ounce,  and 
the  remedy  given  more  frequently.  Of  astringent  tinctures,  like  the  Tinc- 
ture of  Catechu,  Tinctura  Catechu,  the  Tincture  of  Kino,  Tinctura  Kino, 
and  the  Tincture  of  Rhatany,  Tincttira  Krameria,  you  may  prescribe 
from  half  a  drachm  or  a  drachm  to  three  drachms  in  a  mixture,  and  you 
may  give  this  once  in  three  hours,  or,  if  the  diarrhoea  is  severe,  once  in 
two  hours.  Many  practitioners  order  one  of  these  astringent  tinctures 
with  chalk.  Chalk  Mixture,  Mistura  Cretcz,  and*  the  Aromatic  Powder 
of  Chalk,  Pulvis  Cretce  Aromaticus,  are  valuable  remedies  in  ordinary 
cases  of  slight  diarrhoea.  If  there  is  anything  irritating  the  bowels,  it 
must  be  removed,  or  the  diarrhoea  will  continue.  As  I  have  already 
explained,  p.  146,  a  purgative  is  necessary  to  expel  the  irritating  mat- 
ters before  the  diarrhoea  will  cease. 

Next,  with  regard  to  the  use  of  Opium. — If  the  diarrhoea  has  lasted 
for  a  considerable  period  of  time,  and  the  patient  is  becoming  weak  and 
exhausted,  and  you  have  reason  to  believe  that  instead  of  the  bowels 
being  filled  with  irritating  matter,  they  are  empty  or  nearly  empty,  the 
mucous  membrane  irritable  and  sore,  with  constant  and  irregular  con- 
tractions of  the  muscular  coat,  giving  rise  to  severe  griping  and  excruci- 
ating pain,  you  will  find  Opium  a  most  valuable  remedy.  In  such  cases 
small  doses  frequently  repeated  answer  best.  You  may  give  five  or  ten 
drops  of  Laudanum  in  each  dose  of  a  mixture  for  an  adult,  half  as  much 
in  the  case  of  young  people,  but  bear  in  mind  that  Opium  must  not  be 
given  in  any  form  to  young  children.  I  prefer  to  give  Opium  in  severe 
cases  of  diarrhoea  in  the  solid  form.  A  quarter  of  a  grain  of  solid  Opium, 
or  half  as  much  of  the  extract,  Extractum  Opii,  for  a  dose.  The  com- 
position of  Dover's  powder  is  known  to  most  of  you.  Two  grains  will 
contain  one-fifth  of  a  grain  of  Opium.  This  quantity  or  more  of  Dover's 
powder,  the  compound  Ipecacuanha  powder,  Pulvis  Ipecacuanha  Com- 
positus,  may  be  given  in  the  form  of  a  pill  once  in  three  or  four  hours 
if  the  diarrhoea  persists.  Or  you  may  give  the  patent  medicine  Chloro- 
dyne,  which  is  so  well  known — perhaps  too  well  known — to  non-profes- 
sional persons.  Chlorodyne  is  a  mixture  of  many  things,  but  it  un- 
doubtedly acts  beneficially,  and  agrees  with  some  persons  who  cannot 
take  ordinary  preparations  of  opium.  Many  other  remedies  are  fre- 
quently ordered,  but  I  cannot  refer  to  them  in  this  place. 

INTESTINAL  WORMS. 

I  will  here  make  a  few  remarks  upon  the  important  subject  of  intestinal 
worms,  for  some  of  these  parasites  are  often  the  cause  of  slight  ailments, 
and  at  many  different  periods  of  life.  It  is,  however,  during  childhood 
that  illnesses  depending  upon  the  irritation  of  intestinal  worms  are  most 


TREATMENT  OF  WORMS.  1 53 

commonly  met  with.  The  ailment  may  vary  from  a  slight,  but  almost 
constant,  uneasiness  or  pain  in  the  stomach,  occasioning  or  accompanied 
by  irritability  of  temper,  to  a  very  serious  disturbance  of  the  nervous 
system,  characterized  by  attacks  of  convulsions,  and  even  unconsciousness, 
— in  fact,  by  the  epileptic  condition,  a  form  of  illness  which  cannot  be 
regarded  as  slight,  and  classed  under  the  head  of  slight  ailments,  although 
the  affection  almost  always  terminates  in  recovery. 

The  intestinal  worms  most  commonly  observed  in  children  are  called 
Thread  Worms,  from  their  resemblance  to  small  pieces  of  thread. 

Oxyuris  vermicularis. — The  little  Thread  Worms  are  sometimes  found 
in  immense  number  in  the  faeces  of  children,  and  occasionally  they  trouble 
adults.  The  worms  are  male  and  female,  the  former  being  the  smaller 
of  the  two.  The  female  is  seldom  more  than  half  an  inch  in  length. 
They  inhabit  the  lower  part  of  the  large  bowel,  and  breed  in  immense 
numbers  in  the  rectum.  The  eggs  are  oval,  and  are  not  more  than  the 
one  five-hundredth  of  an  inch  in  length  in  their  longest  dimensions. 
They  are  produced  in  countless  multitudes,  and  can  generally  be  demon- 
strated easily  enough  by  microscopical  examination  of  the  matter  passed 
by  the  bowel  in  cases  in  which  thread  worms  have  been  observed. 

Children  suffering  from  thread  worms  are  often  fidgety,  fractious,  and 
excitable.  They  generally  complain  of  itching  about  the  rectum ;  and 
not  unfrequently  the  mucous  membrane  of  the  nose  and  of  the  lips  is  in 
an  irritable  condition.  Sometimes  there  is  diarrhoea  and  discomfort 
referred  to  the  lower  part  of  the  abdomen. 

In  order  to  get  rid  of  these  minute  pests  you  may  begin  with  purgatives. 
A  few  doses  of  Castor-oil  will  often  bring  away  hundreds  of  worms. 
Compound  Jalap  Powder,  Pulvis  Jalapa  Compositus,  in  doses  of  from 
five  to  twenty  grains,  according  to  age.  Compound  Scammony  Powder, 
Pulvis  Scammonii  Compositus,  is  still  more  efficacious,  but  must  be  given 
with  caution  in  the  case  of  weak  children  in  doses  of  from  two  to  ten 
grains.  But  of  all  the  remedies  for  the  destruction  of  thread  worms, 
bitter  infusions  are  the  most  potent;  and  Quassia  is,  I  think,  the  best. 
An  infusion  of  Quassia  may  be  made  by  placing  a  tablespoonful  of 
Quassia  wood-chips  or  shavings  in  a  jug  and  pouring  upon  them  about 
a  pint  of  Cold  Water.  In  an  hour  it  may  be  strained.  A  child  may 
take  an  ounce  or  more  of  the  clear  bitter  infusion  twice  or  three  times  a 
day.  But  it  is  more  efficacious  to  inject  the  infusion  of  Quassia  into  the 
rectum ;  and  if  common  salt  be  added,  in  the  proportion  of  about  a  table- 
spoonful  to  a  pint  of  the  infusion,  it  will  act  more  efficiently.  In  bad 
cases,  about  a  quarter  of  a  pint  or  more  may  be  injected  daily  into  the 
bowel  with  the  aid  of  a  little  India-rubber  ball  syringe.  If  the  worms 
are  not  very  numerous,  once  or  twice  will  be  sufficient.  Some  cases  will 
resist  for  a  long  time  all  the  remedies  that  you  may  try ;  but  if  you 
continue  to  use  the  injections  steadily,  the  case  will  at  length  yield  to 
treatment,  though  the  patient  may  long  have  to  exercise  great  care  as 


154  GIDDINESS. 

regards  diet,  if  he  would  continue  free  from  the  troublesome  parasites. 
The  tendency  manifested  by  the  large  bowel  of  some  persons  to  favor 
the  growth  and  multiplication  of  these  little  Ascarides  is  very  remarkable, 
and  cannot  be  easily  explained.  I  feel  sure  that  in  some  cases  which 
have  been  completely  cured  by  treatment,  a  fresh  importation  of  parasites 
into  the  intestines  has  taken  place  months  afterwards.  Other  persons, 
and  even  members  of  the  same  family,  eating  the  same  food  and  living 
under  similar  conditions,  pass  through  life  without  being  once  troubled 
by  worms. 

The  large  round  worm,  Ascaris  Lumbricoides,  is  occasionally  met  with. 
The  female  is  much  larger  than  the  male,  and  sometimes  attains  the 
length  of  twelve  inches.  It  is  of  a  pale-brownish  color,  round,  about  a 
quarter  of  an  inch  or  more  in  thickness,  and  tapering  off  at  each  end  to 
a  thin  rounded  extremity.  The  male  is  only  five  inches  long.  These 
worms  are  seldom  numerous,  and  usually  not  more  than  from  two  to  four 
exist  in  one  individual.  They  live  in  the  small  intestine,  but  often  pass 
downwards  and  escape  when  the  bowels  act.  Occasionally  they  make 
their  way  into  the  stomach,  and  are  vomited  or  pass  into  the  mouth  or 
nose,  to  the  annoyance,  and  perhaps  terror,  of  the  patient. 

Hundreds  of  thousands  of  eggs  are  formed  and  discharged  by  a  single 
parasite.  The  eggs  are  oval,  and  about  one  three-hundred-and-fiftieth 
of  an  inch  in  the  longest  diameter;  and  multitudes  are  sometimes  found 
in  the  matter  passed  from  the  bowel  by  the  patient  when  subjected  to 
microscopical  examination.  They  may  be  seen  by  an  inch  or  half-inch 
object-glass. 

One  of  the  most  potent  remedies  for  the  round  worm  (Ascaris  Lumbri- 
coides)  is  Santonin,  the  active  principle  of  Santonica,  which  consists  of 
ttie  unexpanded  flowers  of  some  species  of  Artemisia,  or  Wormwood. 
The  dose  of  Santonin  is  two  or  three  grains  for  a  child,  and  double  the 
quantity  may  be  taken  by  an  adult.  Santonica  is  the  unexpanded  flower- 
heads,  as  imported  from  Russia,  from  which  the  active  principle  Santonin, 
Santoninum,  is  obtained.  The  dose  of  the  flower-heads  is  from  ten  to 
fifty  grains. 

The  only  other  entozoon  I  need  mention  here  is  the  Tapeworm,  of 
which  more  than  one  species  is  met  with  in  the  human  organism.  The 
medicine  which  is  the  most  efficacious  in  expelling  the  Tapeworm  is  the 
Oil  or  Liquid  Extract  of  the  Male  Fern ;  but  the  remedy  requires  to  be 
given  in  a  particular  manner,  after  the  patient  has  fasted  for  several 
hours.  I  shall  have  to  consider  Tapeworm  and  its  treatment  in  another 
part  of  my  course. 

VERTIGO,  GIDDINESS. 

Vertigo,  swimming  in  the  head  or  giddiness,  is  an  indication  some- 
times of  disturbed  action  of  the  stomach  and  liver,  and  sometimes  of 
deranged  circulation  and  disturbed  heart's  action.  But  this  symptom 


VERTIGO.  155 

may  also  be  due  to  affections  of  parts  of  the  nerve-structure  of  the  brain, 
or  the  smallarteries  which  supply  it.  The  exact  seat  of  the  lesion  may 
vary ;  but  in  animals,  injury  to  the  crus  cerebri,  as  well  as  certain  injuries 
to  the  cerebellum,  are  followed  by  vertigo.  For  one  case,  however,  of 
vertigo  which  is  due  to  serious  disease  of  the  brain  or  its  vessels,  we 
shall  meet  with  ten  or  more  which  depend  upon  temporary  derangement 
of  the  digestive  organs. 

The  giddy  feeling  after  waltzing  for  too  long  a  time,  or  turning  round 
many  times  on  one  leg,  is  within  the  experience  of  most  of  us,  and  is  a 
form  of  vertigo.  You  will  find  in  some  works  on  brain  affections  that 
vertigo  is  mentioned  as  a  prominent  symptom  of  serious  cerebral  disease. 
If,  however,  a  patient  comes  to  you  complaining  of  vertigo,  do  not  at 
once  shake  your  head  and  look  grave,  even  if  you  have  read  records  of 
cases  in  which  it  undoubtedly  was  a  symptom  of  some  terrible  disease  of 
the  brain  or  cerebellum,  or  was  discovered  to  be  due  to  some  tumor  or 
other  incurable  morbid  growth;  for  if  you  do  give  a  dismal  opinion  you 
may  afterwards  discover  that  you  have  given  a  foolish  one.  You  ought 
to  know  that  this,  like  many  other  symptoms,  may  be  due  to  a  \mere 
transient  disturbance  in  connection  with  the  circulation,  or  of  the  nerves 
presiding  over  the  calibre  of  vessels,  distributed  to  a  very  limited  area 
of  brain  tissue.  You  must  not  forget  that  giddiness  may  be  brought 
about  by  distal  derangement,  as  well  as  by  local  temporary  or  permanent 
change.  Temporary  derangement  of  the  stomach  or  liver,  and  probably 
very  slight  changes  affecting  both,  will,  as  I  have  said,  account  for 
vertigo  as  it  occurs  in  many  cases  which  will  come  under  your  notice. 
There  is  a  form  of  vertigo  which  is  due  to  mere  fancy  or  imagination. 
Having  experienced  the  feeling  of  giddiness  on  one  or  two  occasions, 
patients  often  fancy  it  is  continually  coming  on.  Violent  attacks  of 
coughing,  especially  in  the  case  of  weak  persons,  may  occasion  severe 
attacks  of  vertigo.  Patients  who  have  been  ailing  for  some  time,  though 
not  suffering  from  any  definite  malady,  and  those  who  have  long  been 
troubled  with  loss  of  appetite  or  impaired  digestion,  are  frequently  sub- 
jects of  vertigo,  and  may  often  be  cured  by  judicious  management,  as 
regards  diet  and  wine  or  other  stimulants,  without  any  medicine.  Small 
quantities  of  good  soup,  at  intervals  of  a  few  hours,  and  two  or  three 
glasses  of  Burgundy  or  port  wine  daily,  for  a  short  time,  may  be  ordered 
in  such  cases,  and  will  often  cure  the  giddiness  and  restore  the  general 
health  in  a  week  or  two. 

There  are  some  persons  who  are  very  frequently  troubled  with  a  curiout 
form  of  vertigo  or  giddiness,  not  arising  from  any  organic  lesion,  or 
leading  to  any  change  which  shortens  life,  or  which  may  even  seriously 
derange  the  health.  In  not  a  few  instances  vertigo  is  due  to  excessive 
nervousness.  I  have  known  highly  nervous  people  of  both  sexes  suffer 
from  the  most  severe  vertigo,  preventing  them  from  walking  for  many 
days,  and  for  a  time  liable  to  come  on  if  the  head  was  only  slightly  raised 


156  VERTIGO. 

from  the  pillow.  Sometimes  disturbed  co-ordinating  power  of  the  mus- 
cles of  the  eye-ball  is  accompanied  by  giddiness.  Vertigo  occurs  in 
many  cases  of  blood-poisoning,  and  in  some  forms  of  fever.  It  may  be 
brought  on  by  sudden  loss  of  a  considerable  quantity  of  blood,  as  from 
hemorrhage  ;  and  it  often  occurs  in  anaemia.  In  some  forms  of  epilepsy 
vertigo  is  a  prominent  symptom. 

The  word  vertigo  comes  from  vertex  or  vortex,  a  whirlwind,  which  is 
derived  from  "Verfo,  I  turn."  The  sensation  is  sometimes  described  as 
a  swimming  in  the  head.  Objects  seem  to  be  moving  in  a  strange  and 
irregular  manner.  Many  cannot  look  from  a  great  height  downwards 
without  feeling  giddy.  Vertigo  may  be  brought  on  by  taking  certain 
substances.  Opium  will  cause  it,  also  Belladonna ;  alcohol  causes  it  very 
commonly.  Any  one  who  has  seen  a  person  a  little  tipsy  knows  how  his 
power  of  co-ordinating  the  muscular  movements  of  his  body  is  impaired, 
and  how  he  rolls  about  from  one  side  to  the  other ;  and  in  consequence 
of  feeling  giddy  is  unable  to  walk  in  a  straight  line.  Tobacco  will  also 
give  rise  to  a  form  of  vertigo,  especially  when  it  is  brought  into  contact 
with  nerves  and  nerve-centres,  which  have  not  gradually  become  accus- 
tomed to  its  influence.  A  slight,  temporary  failure  in  the  force  of  the 
heart's  action  may  cause  marked  giddiness ;  and  the  attacks  may  recur 
from  time  to  time,  causing  much  anxiety  to  the  patient  and  his  friends. 
A  few  doses  of  Sal  Volatile  or  brandy  frequently  relieve  this  form  of 
vertigo.  Only  a  teaspoonful  or  less  of  the  stimulant  is  required,  diluted 
with  not  more  than  double  the  quantity  of  water. 

Peculiar  disturbances  in  vision  occur  in  many  cases  of  vertigo.  Things 
look  crooked.  Some  see  only  a  portion  of  an  object.  They  can  see  the 
upper  half  without  being  able  to  see  the  lower  half  of  a  person,  and  so 
on:  These  disturbances  of  vision  do  not  necessarily  imply  anything 
more  severe  than  temporary  functional  disturbance,  perhaps  due  to  some 
irregular  distribution  of  blood  in  the  capillary  vessels  of  parts  of  the 
central  ganglia,  consequent  upon  sudden  alterations  in  calibre  of  the 
small  arteries,  caused  by  disturbed  action  of  the  nerve  ganglia  which  regu- 
late and  preside  over  the  action  of  the  coats  of  these  particular  vessels. 
Such  symptoms  may  mean,  it  is  true,  something  far  more  serious,  but  in 
many  cases  they  certainly  depend  upon  no  more  grave  or  important 
changes  than  may  be  determined  by  taking  a  little  more  wine  than  is 
good.  Swimming  in  the  head  is  by  many  considered  a  fo.rm  of  vertigo. 
Persons  who  have  been  for  some  time  over-anxious,  or  who  have  been 
overtaxing  the  mind  or  body,  may  suffer  in  this  way.  In  the  last  case, 
the  unpleasant  symptoms  will  sometimes  disappear  ten  minutes  after  tak- 
ing a  dose  of  Sal  Volatile  or  an  alcoholic  stimulant.  If,  however,  they 
do  not  do  so,  they  will  probably  be  relieved  by  a  little  attention  to  diet, 
by  a  dose  or  two  of  Calomel  or  Blue  Pill.  The  general  health  may 
afterwards  be  improved  by  taking  a  tonic,  containing  acid  and  bark, 
for  a  week  or  two. 


BILIO  USNESS.  157 

Aural  Vertigo. — Disease  and  injury  to  the  semicircular  canals  of  the 
ear  may  cause  a  feeling  of  giddiness  and  a  tendency  to  fall,  as  well  as 
vertiginous  movements,  the  direction  of  which,  forwards,  backwards,  or 
from  side  to  side,  is  determined  by  the  particular  semicircular  canal  which 
is  affected.  Men i ere,  as  long  ago  as  1861,  directed  attention  to  a  class 
of  cases  in  which  noise  in  one  ear, — humming,  buzzing,  whistling,  puffing, 
— often  associated  with  pallor,  headache,  faintness,  giddiness,  nausea,  and 
vomiting  occurred  in  connection  with  disease  of  the  semicircular  canals, 
or  of  other  parts  of  the  ear.  The  attacks  at  first  are  slight  and  occa- 
sional, but  gradually  the  -noises  in  the  head  increase  in  intensity,  and 
are  almost  constant.  At  last  absolute  deafness  of  the  affected  ear  ensues, 
and  in  consequence  of  the  nerve-structures  being  destroyed,  the  giddi- 
ness and  other  symptoms  cease. 

You  will,  however,  meet  with  the  symptoms  above  enumerated  in  cases 
in  which  there  is  no  reason  to  suppose  that  organic  disease  of  the  ear  or 
any  other  organ  exists.  The  attacks,  after  recurring  several  times  at 
intervals  during  many  years,  will  at  last  cease,  leaving  the  patient  per- 
fectly well.  Some  of  these  cases  seem  to  belong  to  the  category  of  sick 
headache,  and  the  attacks  will  be  relieved  by  a  small  dose  of  Calomel, 
Blue  Pill,  or  Grey  Powder,  Hydrargyrum  cum  Cretd.  In  such  instances 
it  is  very  probable  that  there  is  temporary  disturbance  of  the  circulation 
in  the  internal  ear,  as  well  as  in  other  parts.  Moreover,  very  nervous, 
fanciful  people  will  sometimes  complain  of  the  symptoms  of  Meniere's 
disease,  but  as  they  quite  recover  under  the  influence  of  tonics,  good 
living,  and  change  of  air,  it  is  more  likely  that  the  symptoms  were  due 
to  slight  and  temporary  nerve  disturbance,  than  to  definite  morbid 
change  affecting  nerve  or  other  tissue. 

BILIOUSNESS. 

It  is  difficult  to  adequately  explain  the  various  phenomena  which  con- 
stitute what  is  known  as  biliousness,  although  very  many  persons  are  well 
acquainted  with  the  symptoms  of  the  bilious  condition,  and  have  fre- 
quently experienced  them.  Whether  there  is  congestion  of  the  liver  in 
all  cases,  I  cannot  tell,  for  I  am  glad  to  say  that  I  never  saw  a  post-mor- 
tem of  any  one  who  had  died  during  an  attack  of  biliousness.  Whatever 
may  be  the  essential  nature  of  the  malady,  it  is  not  fatal.  Nay,  bilious 
people  are  for  the  most  part  long-lived.  Some  physicians  who  have  expe- 
rience in  connection  with  life  insurance  business,  so  far  from  objecting 
to  take  bilious  people,  are  desirous  of  insuring  them.  In  this  opinion  I 
fully  concur.  There  is  no  doubt  that  a  tendency  to  biliousness  makes 
people  very  careful  as  to  their  mode  of  living.  They  know  that  if  they 
exceed  they  will  suffer.  Bilious  persons  are  often  very  fidgety  about 
their  diet,  for  if  they  eat  too  much  a  bilious  attack  usually  comes  on,  and 
for  a  time  they  are  completely  unfit  for  ordinary  work.  Although  bil- 
iousness is  anything  but  an  agreeable  malady,  nevertheless  you  may  gen- 


158  PATHOLOGICAL    CHANGES. 

erally  recommend  bilious  patients  with  confidence  for  various  occupations 
in  which  endurance  is  required.  The  capacity  for  going  steadily  on  for 
a  long  period  of  time  is  in  truth  often  associated  with  a  bilious  habit  of 
body.  I  fancy  a  very  large  share  of  the  best  work  of  the  world  is  per- 
formed by  the  bilious.  Such  a  tendency  is  frequently  characterized  by 
much  energy  and  determination  to  work  in  spite  of  the  derangement, 
and  although  there  may  be  also  some  irritability  of  temper  or  despond- 
ency, there  is  frequently  a  very  remarkable  degree  of  patience,  persist- 
ence, and  resisting  power. 

Although  I  cannot  give  an  accurate  description  of  the  pathological 
phenomena  of  biliousness,  I  may  help  you  to  form  an  idea  of  the  sort 
of  unpleasant  sensations  experienced  by  bilious  people,  if  I  describe  in 
his  own  words,  the  sufferings  of  a  gentleman  who  had  been  bilious  all 
his  life,  but  who  nevertheless  managed  to  live  to  a  very  advanced  age. 
My  friend  was  a  man  who  might  have  done  great  things  and  left  his  mark  ; 
but  I  fear  he  lost  much,  and  perhaps  the  world  more,  in  consequence  of 
his  not  being  obliged  to  work.  As  in  some  other  cases,  a  fortune  is  after 
all  a  misfortune.  He  was, -moreover,  unwise  enough  to  allow  himself  to 
get  into  that  habit  of  thinking  too  much  about  slight  physiological  de- 
rangements which  occurred  in  his  own  organism,  and  he  gradually  got 
into  the  bad  habit  of  frequently  talking  to  his  friends  about  his  aches  and 
pains.  Being  rich,  he  was  listened  to,  and  further  was  spoiled  by  the  sym- 
pathy and  pity  foolishly  lavished  upon  him.  As  age  advanced,  the  inter- 
est of  his  environment  seemed  to  him  to  diminish,  while  the  growls  and 
grumblings,  excited  by  sensations  within  himself,  became  so  loud  that  at 
length  he  determined  to  seek  professional  consolation.  He  consulted 
the  most  celebrated  physicians,  but  no  one  succeeded  in  curing  his  bil- 
iousness, or  in  teaching  him  to  bear  it  patiently.  He  grievously  trou- 
bled his  family  by  his  reiterated  complaints,  and  by  his  persistent  anx- 
iety about  himself.  Though  on  occasions  he  felt  pretty  well  for  a  day 
or  two,  during  many  years  he  failed  to  make  himself  contented  or  happy. 
Every  kind  of  treatment  was  tried,  but  nothing  cured  the  derangement 
or  averted  the  attacks.  Blue  Pill  afforded  some  relief,  and  was  the  only 
remedy  persisted  in  from  first  to  last.  All  his  tissues  were  probably 
sound,  and  I  doubt  whether  there  was  any  serious  morbid  change  in  any 
organs  after  more  than  ninety  years  of  work.  This  gentleman  was  seen  by 
me  many  times,  and  wrote  down  for  me  a  description  of  his  sufferings. 
Here  it  is:  "Flatulence,  distention  of  the  bowels,  and  painful  sensa- 
tions between  the  shoulders;  coldness  of  the  feet,  twinging  pains  occa- 
sionally under  the  right  shoulder-blade,  nausea  after  eating.  Muscular 
pain  about  the  head  and  neck — particularly  the  muscles  at  the  back  of 
the  neck."  The  last  is  a  very  common  symptom,  and  a  very  painful 
one  in  many  cases  of  biliousness,  and  recurs  in  almost  every  attack. 
This  old  gentleman  ate  too  much,  and  no  wonder  he  was  disturbed  at 
night,  and  had  to  complain  of  "  harassing  and  long-distressing  dreams." 


DERANGEMENT  OF  THE  LIVER.  159 

He  also  suffered,  as  very  many  old  people  do,  from  "  irritation  of  the 
skin  of  the  body  generally,  but  of  his  legs  principally,  and  from  sore- 
ness and  eruptions  about  the  mouth,  affecting  chiefly  the  upper  lip." 
Such  was  the  long  catalogue  of  recorded  symptoms,  and  the  list  by  no 
means  exhausts  all  this  old  gentleman's  complaints. 

Some  who  suffer  from  biliousness  differ  from  my  old  friend,  and  seem 
to  alternate  between  a  state  of  misery  and  despair  and  a  state  of  com- 
parative comfort  and  even  hopefulness.  You  will  sometimes  find  patients 
bilious  and  irritable  and  out  of  temper,  and  very  indisposed  to  do  what 
you  may  wish,  unless  indeed  they  have  sufficient  self-command  to  over- 
come their  natural  bent.  Another  time  you  will  find  the  same  persons 
in  excellent  spirits,  and  ready  to  do  anything  for  you,  and  as  agreeable 
as  possible.  We  may  have  very  contradictory  accounts  of  the  same  indi- 
vidual ;  one  person  tells  us  that  he. is  a  most  disagreeable,  cantankerous 
person,  while  another  affirms  him  to  be  a  most  pleasant  and  excellent 
man.  The  conflict  of  testimony  is  explained  by  the  circumstance  that 
one  informant  happened  to  see  him  when  he  was  bilious,  while  the  other 
came  in  contact  with  him  just  after  he  had  recovered  from  an  attack. 

It  seems  curious  that  we  should  not  be  able  to  fully  explain  such  very 
prominent  and  persistent  functional  derangements  as  affect  important 
organs  in  cases  of  biliousness,  more  especially  as  the  condition  is  a  com- 
mon one,  and  has  been  often  experienced  by  well-trained  scientific  and 
thoughtful  members  of  our  profession.  But  I  have  never  been  able  to 
get,  from  any  physicians  with  whom  I  have  conversed  or  from  any  books 
I  have  read,  what  seems  to  me  to  be  a  clear  and  satisfactory  account  of 
the  disturbance  which  occurs  in  an  attack  of  biliousness,  or  of  the  actual 
changes  which  affect  the  action  of  the  peccant  organs  during  the  preva- 
lence of  the  attack.  There  is,  however,  no  doubt  that  at  the  time  there 
is  actual  disturbance  in  the  liver.  When  biliousness  is  experienced,  the 
changes  taking  place  in  this  organ,  as  well  as  in  the  stomach,  differ  in 
important  particulars  from  those  which  occur  under  ordinary  circum- 
stances. 

The  liver  is  not  concerned  merely  in  the  secretion  of  that  fluid  which 
we  know  as  the  bile,  but  it  has  to  do  with  many  other  changes.  Among 
the  most  remarkable  phenomena  of  the  liver  are  its  sugar-  and  fat-pro- 
ducing powers.  It  also  effects  great  changes  in  albuminous  matters  and 
peptones,  which  have  just  been  taken  up  by  the  vessels  of  the  intestines 
and  carried  to  it  dissolved  in  the  portal  blood. 

Concerning  any  slight  derangements  which  the  sugar- forming  func- 
tions of  the  liver  no  doubt  undergo  from  time  to  time,  we  know  com- 
paratively little ;  but  we  do  know  that  these  functions  may  be  so  disturbed 
as  to  result  in  the  establishment  of  a  most  serious  change  in  the  action 
of  the  organ  which,  when  once  started,  usually  persists,  and  at  length, 
at  least  in  the  case  of  the  young,  ends  in  death.  In  Diabetes,  particu- 
larly as  it  occurs  in  the  young,  many  ounces  of  sugar  are  formed  during 


l6o  BILIOUSNESS. 

each  period  of  twenty-four  hours,  and  the  kidneys  are  chiefly  concerned 
in  the  removal  of  this  sugar  from  the  blood,  although  the  tears  and  other 
secretions  also  contain  sugar  when  the  diabetic  state  is  established.  This 
formation  of  sugar,  although  varying  in  activity  from  time  to  time,  and 
under  the  influence  of  remedies,  cannot  certainly  be  stopped.  It  con- 
tinues in  the  great  majority  of  well-marked  cases,  and  gradually  exhausts 
the  patient,  until,  after  a  period  varying  from  a  few  months  to  two  or 
three  years,  death  results.  On  the  other  hand,  I  may  confidently  state 
that,  under  certain  conditions,  which  cannot  be  exactly  defined,  the  liver 
may  be  seriously  deranged  as  regards  its  sugar-forming  functions,  not  only 
without  causing  death,  but  even  without  apparently  deranging  the  general 
health  or  nutrition  of  the  patient.  In  old  age  it  is  not  an  uncommon 
thing  to  find  a  certain  amount,  and  occasionally  an  enormous  quantity, 
of  sugar  in  the  urine  of  a  person,  although  its  presence  was  quite  unex- 
pected. It  would  seem  that,  in  old  age,  the  sugar-forming  action  of  the 
liver  may  be  greatly  in  excess  of  what  it  is  in  the  normal  state,  and 
although  the  sugar  pervades  the  blood  and  is  carried  by  it  to  the  various 
tissues  and  organs  of  the  body,  it  scarcely  seems  to  disturb  their  action. 
At  any  rate,  it  may  continue  uninterruptedly  for  more  than  twenty  years, 
and  the  patient  may  die  at  an  advanced  age  of  some  other  malady.  Not 
only  so,  but  any  healthy  person  may  for  a  time  form  considerable  quan- 
tities of  diabetic  sugar,  if  he  will  take  more  than  a  moderate  quantity 
of  cane  sugar.  A  man  who  took  a  dose  of  a  quarter  of  a  pound  of  ordi- 
nary sugar  passed  diabetic  sugar  in  his  water  for  two  or  three  days  after- 
wards; but  this  temporary  diabetic  state  is  not  to  be  induced  so  easily  in 
every  person.  The  liver  is  the  organ  by  which  the  change  is  effected, 
and  if  you  think  over  these  facts  you  will,  I  think,  agree  with  me  in  the 
conclusion  that,  in  many  slight  derangements  of  the  health,  some  other 
functions  of  the  liver,  instead  of  or  as  well  as  its  bile-forming  office,  are 
at  fault.  The  action  of  the  liver-cells,  in  connection  with  their  influ- 
ence on  the  formation  and  transformation  of  fatty,  albuminous,  and 
amyloid  matters,  must,  therefore,  not  be  lost  sight  of  in  our  efforts  to 
determine  the  causation  of  many  slight  derangements  of  the  health  which 
seem  referable  to  the  liver. 

But  as  regards  "  biliousness,"  it  seems  to  me  that  the  yellow  tinge  of 
the  conjunctiva  so  commonly  observed,  the  alteration  in  the  color  of  the 
skin  and  its  dryness,  the  disturbed  action  of  the  sebaceous  glands,  the 
sense  of  weight  in  the  right  side,  the  derangement  of  digestion — all  point 
to  the  fat-  and  bile-forming  operations  of  the  liver-cells  as  being  mainly 
at  fault.  This  view  is  confirmed  by  the  fact  that  medicines  which  cor- 
rect the  changes  just  referred  to  are  those  which  unquestionably  act  upon 
the  bile-forming  process,  and  as  soon  as  the  action  begins  the  patient  who 
suffers  from  what  is  known  as  a  bilious  attack  experiences  relief.  Some 
cases  of  severe  biliousness  approach  so  nearly  to  those  cases  of  temporary 
jaundice,  which  I  shall  presently  speak  of,  that  I  am  almost  inclined  to 


ON  THE    TREATMENT  OF  BILIOUSNESS.  l6l 

regard  them  as  related  to  that  condition.  Possibly,  it  may  be  correct  to 
consider  biliousness  a  condition  which  initiates  certain  forms  of  jaundice. 
Biliousness  may  possibly  depend  upon  an  inactive  state  of  the  liver-cells, 
in  consequence  of  which  substances  remain  in  the  blood  which  ought  to 
be  separated  from  that  fluid  and  converted  into  bile.  The  sluggish  state 
of  the  circulation,  the  tendency  to  the  accumulation  of  the  blood  in  the 
capillaries  and  veins,  as  shown  by  the  distention  of  the  capillaries  of  the 
papillse  of  the  skin  and  the  bleeding  which  takes  place  if  they  are  di- 
vided, the  formation  or  increase  of  haemorrhoids,  the  turgid  state  of 
capillaries  near  slight  scratches  or  wounds,  and  the  indisposition  of  the 
latter  to  heal,  indicate  such  disturbance  of  the  capillary  circulation  gen- 
erally as  would  result  from  the  accumulation  in  the  blood  of  substances 
which  ought  to  be  thoroughly  eliminated  from  the  circulating  fluid. 

The  Treatment  of  Biliousness. — The  only  medicine  that  relieves  many 
bilious  people  is  a  small  dose  of  some  mercurial  preparation.  The  old 
gentleman  to  whose  case  I  have  already  referred  discovered  that  blue 
pill  alone  gave  him  ease,  and  dissipated  for  a  time  the  unpleasant  sensa- 
tions from  which  he  suffered,  and  which  made  him  at  times  perfectly 
wretched.  He  took  blue  pill  of  his  own  accord,  whether  the  doctors 
allowed  it  or  not.  For  forty  years  he  seldom  went  four  days  without  the 
remedy.  He  tried  over  and  over  again  to  get  out  of  the  habit,  and  many 
advisers  strongly  recommended  him  to  give  up  taking  mercurials.  He 
made  many  attempts,  but  in  a  short  time  his  sufferings  became  so  great, 
that  at  last  he  was  obliged  to  return  to  his  favorite  remedy.  He  seldom, 
however,  took  more  than  a  grain  once  in  four  or  five  days. 

I  do  not  mean  to  imply  that  you  will  cure  every  case  of  biliousness  if 
you  give  mercurials ;  but  certainly  the  great  majority  that  come  under 
your  notice  will  be  benefited.  Many  cases  resist  every  effort  to  cure, 
them,  but  it  is  the  exception  to  meet  with  a  sufferer  who  cannot  be  in 
some  degree  relieved  by  treatment.  The  bilious  habit  seems  to  be  due 
to  an  unusually  sensitive,  irritable  stomach  and  liver,  which  discharge 
their  functions  fairly  in  a  moderate  degree,  but  which  cannot  be  made 
to  perform  more  than  this  moderate  amount  of  work,  without  getting 
much  out  of  order;  so  that  where  you  have  to  treat  patients  suffering 
from  biliousness,  you  must  be  careful  to  give  directions  concerning  diet, 
which  should  be  very  moderate,  *nd  lay  stress  upon  the  importance  of 
great  moderation. 

Most  of  the  organs  taking  part  in  the  digestion  and  assimilation  of  the 
food  seem  to  strike  work  when  a  decided  bilious  attack  comes  on.  •  If 
food  be  taken,  the  suffering  becomes  greater.  Moderate  starvation  is 
what  is  required  in  many  cases.  Bilious  people  often  find  advantage 
from  giving  their  digestive  organs  partial  rest  for  several  days.  In  this 
way  time  is  allowed  for  the  return  of  the  organs  deranged  to  their  nor- 
mal state.  The  fact  seems  to  be  that  the  digestive  organs  require  rest 
for  a  time,  and  if,  when  an  attack  comes  on,  this  rest  is  given,  the  bilious 
14*  L 


1 62  ON  THE   TREATMENT  OF  BILIOUSNESS. 

state  passes  off,  and  then  the  patient  feels  extremely  well,  perhaps  for  a 
considerable  time. 

In  general,  you  will  find  that  those  who  are  liable  to  bilious  attacks 
require  very  little  meat.  Free  meat-eating  will  often  bring  on  an  attack. 
Generally,  rich  foods  do  not  agree.  Fatty  matters  in  certain  forms  and 
in  moderate  proportion  must  be  taken,  but  cooked  and  half-cooked  fatty 
materials,  as  in  many  sauces,  soups,  fried  fish,  and  meats,  are  not  suita- 
ble. Cream  or  much  milk  sometimes  precipitates  an  attack.  Most  forms 
of  alcohol,  and  any  form  in  quantity,  will  generally  disagree  with  the 
patient.  Vegetables  and  many  fruits,  on  the  other  hand,  agree  well; 
vegetable  acids  seem  to  help  the  action  of  the  liver  and  stomach.  From 
half  an  ounce  to  an  ounce  of  lemon  juice  daily  for  a  time  is  undoubt- 
edly useful  in  many  instances.  Cider  in  moderation,  that  is,  one  or  at 
most  two  tumblers  daily,  can  be  taken  by  some  bilious  persons.  Citrates, 
Tartrates,  Acetates,  may  also  be  given.  Light  puddings  composed  of 
starchy  matters  of  various  kinds,  such  as  Rice,  Indian  corn,  Sago,  or 
Tapioca,  made  with  milk  and  eggs  in  small  quantity,  and  plenty  of 
bread,  may  be  enumerated  among  the  articles  of  diet  for  the  bilious. 
Generally,  such  persons  are  of  necessity  small  eaters — their  organs  rebel 
before  it  is  possible  to  damage  them  by  overwork,  and  so  they  seldom 
die  of  those  diseases  which  cut  short  the  life  of  so  many  who  enjoy  good 
living,  and  who  possess  strong  digestive  organs.  Hence,  as  I  have 
already  remarked,  the  bilious  often  live  to  be  old.  When  an  attack 
comes  on,  benefit  often  results  from  the  use  of  mild  purgatives.  Effer- 
vescing Citrates  and  Tartrates  do  good.  Liquor  Ammonia;  Acetatis  and 
Muriate  of  Ammonia  have  been  also  prescribed  with  advantage  in  many 
cases.  I  have  often  recommended  grapes,  in  quantities  of  half  a  pound 
a  day,  when  they  can  be  obtained.  Many  persons  have  been  relieved 
by  taking  from  six  to  ten  tumblers  of  fluid  in  the  course  of  twenty-four 
hours,  for  two  or  three  days  at  a  time.  Ordinary  soda  water,  or  seltzer, 
or  Apollinaris  water  may  be  ordered.  The  kidneys  are  in  this  way  made 
to  act  very  freely,  and  relief  soon  follows. 

Of  the  deleterious  action  of  the  east  wind  upon  the  functional  action 
of  the  liver  there  can  be  no  doubt ;  but  it  is  not  easy  to  explain  precisely 
how  this  results.  That  the  dryness  of  the  air  and  the  constant  wind  are 
potent  in  interfering  with  the  due  <*ction  of  the  skin  there  can  be  no 
question ;  but  these  effects  do  not  afford  an  adequate  explanation  of  the 
facts,  since  persons  shut  up  in  rooms  artificially  heated,  and  with  the  air 
supplied  with  watery  vapor,  nay,  people  who  have  kept  their  beds,  are 
often  aware  when  the  wind  blows  from  the  east.  Northerly  and  westerly 
winds  may  be  as  cold,  and  I  think  as  dry,  as  the  east  winds,  withou; 
giving  rise  to  those  very  unpleasaat  sensations  experienced  by  the  majority 
of  the  population  who  have  passed  their  fourth  decade,  whenever  the 
wind  is  in  the  east.  As  long  as  the  wind  blows  from  this  quarter,  people 
suffer;  but  a  few  hours  after  a  change  has  taken  place  they  feel  perfectly 


„       JAUNDICE.  163 

well,  both  in  body  and  mind  ;  for,  as  is  well  known,  the  temper  is  often 
terribly  ruffled  by  a  dry  east  wind. 

The  seaside  has  the  reputation  of  seriously  impeding  the  action  of  the 
liver ;  and  deservedly  so  ;  for  we  are  assured  by  many  persons  that  when- 
ever they  go  to  the  sea  for  a  week  or  more,  the  motions  are  invariably 
scanty,  and  of  a  very  pale  yellow  or  of  a  gray  color.  But  what  is  very 
remarkable  is  this  :  that  for  some  time  after  their  return  from  the  sea  the 
hepatic  actions  of  the  same  persons  is  unusually  free.  Although  they 
may  consume  much  less  food  than  when  they  were  away,  the  motions  are 
more  abundant  and  the  faecal  matter  properly  formed.  In  these  cases 
there  is  no  doubt  that  there  is  increased  formation  of  faecal  matter — that 
materials  which  had  been  accumulating  for  perhaps  a  fortnight  previously 
are  at  length  separated  from  the  blood,  and  the  patient  in  consequence 
feels  greatly  relieved  and  appears  to  be  much  improved  in  health. 

Where  the  bilious  state  is  very  severe — and  in  some  cases  it  is  so  severe 
as  to  incapacitate  people  from  performing  any  kind  of  work  for  the  time 
— you  will  often  afford  relief,  and  in  a  very  short  time,  if  you  give  a  grain 
or  two  of  Blue  Pill  or  Calomel.  Some  who  suffer  from  biliousness  also 
experience  violent  headache  at  the  time ;  and  this  symptom  is  also  re- 
lieved by  the  Blue  Pill  or  Calomel,  and  frequently  in  the  course  of  a  very 
few  hours  after  the  medicine  has  been  taken.  Indeed,  some  who  suffer 
much,  and  who  are,  generally  speaking,  in  anything  but  a  good  state  of 
health,  may  yet  be  able  to  get  through  their  work  with  the  help  of  an 
occasional  dose  of  a  mercurial — from  one  to  three  grains  of  Gray  Powder 
once  in  five  or  six  days.  I  am  not  aware  that  any  deleterious  effects  are 
produced  by  this  practice  in  persons  who  suffer  much  from  biliousness. 
Of  course  it  is  not  desirable  for  any  one  to  be  continually  taking  mer- 
curials, or  any  other  drugs  for  that  matter ;  but  it  is  better  to  take 
mercurials  now  and  then  than  to  be  utterly  incapacitated  for  one  or  two 
days  out  of  every  ten  or  twelve,  as  is  the  case  with  many  who  suffer  from 
this  most  unpleasant  ailment. 

From  some  experiments  performed  by  Dr.  William  Rutherford  on  the 
dog,  it  appears  that  several  vegetable  substances  act  as  stimulants  to  the 
secretion  of  bile;  and  it  has  been  inferred  that  they  act  upon  man  as 
well  as  upon  the  dog.  Among  the  most  important  of  these  cholagogues 
are  Iridin,  Baptistin,  Juglandin,  of  each  of  which  from  two  to  four  grains 
may  be  prescribed  for  a  dose,  Euonymin  in  doses  of  from  one  grain  to 
two  grains,  and  Phytolaccin,  of  which  the  dose  is  from  one-eighth  of  a 
grain  to  a  grain.  Dr.  Rutherford's  observations  will  be  found  in  the 
"British  Medical  Journal,"  February  Sth,  1879. 

Jaundice  is  a  rather  common  affection,  particularly  in  summer.  It 
may  be  due  to  many  different  causes,  some  of  which  are  unimportant 
and  transient,  while  others  are  serious  and  irremediable.  The  particular 
form  of  jaundice  to  which  I  am  about  to  refer,  may,  with  propriety,  be 
included  under  the  head  of  "slight  ailments."  It  is  known  as  ordinary 


164  EXCRETION  OF  BILIARY  COLORING  MATTER. 

jaundice ;  and  I  dare  say  that  perhaps  thirty  or  more  per  cent,  of  us  have 
suffered  from  an  attack  of  jaundice,  or  will  do  so  before  the  age  of  twenty- 
five  is  passed. 

The  physiological  changes  in  the  system  must  needs  be  very  much 
modified  if  the  bile,  which  is  formed  in  such  considerable  quantity, 
instead  of  being  poured  into  the  intestines,  is  retained  in  the  gall-bladder. 
In  every  form  of  jaundice  the  bile  is  formed  by  the  liver,  but  does  not 
escape  by  its  usual  channel.  Most  commonly  the  Common  Gall-Duct, 
Ductus-Communis  Choledochus,  is  plugged  up;  and  the  bile,  which  has 
been  formed  by  the  cells  of  the  liver,  and  has  passed  into  the  gall-ducts, 
is  obstructed  in  its  further  course  towards  the  intestine.  After  accumu- 
lating to  some  extent  in  the  ducts,  and  in  the  gall-bladder,  it  would 
appear  that  it  gradually  makes  its  way  through  their  coats,  and  gains 
entrance  to  the  lymphatics  and  veins  which  lie  outside  them.  Hence 
the  bile  formed  by  the  liver  soon  passes  into,  and  circulates  with,  the 
blood.  Tissues  in  all  parts  of  the  body  become  stained,  and  in  some 
cases  take  a  deep  yellow  color.  Textures,  both  at  the  surface  and  in  the 
interior  of  the  body,  are  thus  stained  more  or  less  intensely  in  cases  of 
jaundice. 

Not  only  so,  but  the  excretion  of  the  yellow  coloring  matter  which 
has  been  formed  originally  in  the  liver,  and  has  been  absorbed  into  the 
blood,  is  effected  to  some  extent  by  the  kidneys.  Mucus,  epithelial 
cells,  casts,  and  even  some  crystals  passed  in  the  urine  are  tinged  of  a 
bright  yellow  color,  while  the  urine  itself  contains  a  good  deal  of  yel- 
low biliary  matter.  Sometimes  it  appears  of  a  dar-k-green  color,  owing 
to  the  quantity  of  bile  it  contains.  So  quickly  in  many  instances  is  the 
bile  removed  from  the  blood  by  the  kidneys  that  the  urine  is  often  stained 
with  the  characteristic  yellow  color  for  some  days  before  the  skin  acquires 
the  slightest  yellow  tint.  On  the  other  hand,  the  secretions  from  the 
bowels  will  be  found  to  lose  the  ordinary  color,  and  after  the  jaundice 
has  lasted  a  short  time  they  will  be  clay-colored  or  colorless. 

Whether  the  impediment  which  'interferes  with  the  passage  of  the  bile 
into  the  intestine,  in  these  cases  of  temporary  jaundice,  is  due  to  firm 
spasmodic  contraction  of  the  muscular  fibres  which  surround  the  lower 
part  of  the  common  gall-duct  near  its  opening  in  the  duodenum,  or  to 
the  accumulation  of  mucus  and  epithelium  in  the  same  situation,  thus 
plugging  the  duct,  is  not  quite  certain  ;  but  there  can  be  no  doubt  that 
there  is  in  all  these  cases  an  impediment  to  the  onward  flow  of  the  bile, 
consequent  upon  some  temporary  obstruction,  which  after  a  period  vary- 
ing from  a  week  to  three  months  or  longer  gives  way  without  any  per- 
manent change  or  derangement  being  induced.  Patients  suffering  from 
temporary  jaundice  completely  recover. 

Now  I  desire  to  ask  your  careful  attention  to  the  fact  that  in  these  cases 
the  jaundice  is  due  not  to  the  accumulation  in  the  blood  of  substances 
out  of  which  bile  might  be  formed  by  the  action  of  the  liver-cells,  but 


SEVERE  JAUNDICE.  165 

to  the  passage  into  the  blood  of  bile  which  has  been  already  formed  by 
the  action  of  these  hepatic  elements,  and  has  passed  into  the  ducts. 

As  I  have  already  said,  the  stools  appear  more  or  less  like  clay,  or  of 
very  light-brown  color,  in  consequence  of  the  biliary  matter  not  having 
passed  into  the  intestines,  where  ordinarily  it  undergoes  those  compli- 
cated changes  which  take  place  in  its  resinous  acids  and  coloring  matter, 
and  which  end  at  last  in  the  development  of  the  peculiar  chemical  com- 
pounds which  are  constantly  found  in  normal  faecal  matter. 

Even  in  slight  cases  of  jaundice  the  bowels  are  usually  somewhat  con- 
fined. The  patient  perhaps  experiences  slight  nausea,  with  indisposition 
to  take  food.  He  gets  thin.  The  nutriment  matters  he  does  take  do  not 
nourish  him  properly,  and  he  feels  weak  and  out  of  health.  Some  people 
suffering  from  jaundice  are,  however,  able  to  do  their  work,  and  students 
have  passed  through  a  difficult  examination  although  they  were  deeply 
jaundiced ;  but  the  proceeding  is  not  a  wise  one. 

You  see,  therefore,  that  a  very  large  and  important  organ  like  the  liver 
may  be  seriously  deranged»without  the  ordinary  functions  of  the  other 
organs  of  the  body  being  very  seriously  disturbed.  For  a  time  at  least 
we  can  get  on  not  only  without  bile  flowing  into  the  intestine,  but  in 
spite  of  its  distribution  to  all  parts  of  the  body.  In  these  cases,  the  bile 
prevented  from  escaping  from  the  liver  is  reabsorbed  and  taken  up  by 
the  blood,  and  the  coloring  matter  deposited  in  many  of  the  tissues. 
The  patient  may,  however,  notwithstanding  this  great  change,  be  able  to 
perform  a  certain  considerable  amount  of  work,  and  may  be  able  to 
use  his  mind  efficiently,  although  the  whole  of  the  blood  distributed  to 
his  brain  is  contaminated  with  a  considerable  proportion  of  biliary 
matter. 

But,  as  I  have  remarked,  you  must  bear  in  mind  that  from  time  to  time 
cases  of  jaundice  are  met  with  which  end,  and  very  quickly  too,  most 
disastrously.  It  is  a  fact  which  must  not  be  forgotten,  that  some  of  these 
cases  which  may  run  on  to  a  fatal  termination  in  the  course  of  two  or 
three  weeks,  cannot  at  their  commencement  be  distinguished  from  that 
almost  trivial  form  of  jaundice  of  which  I  have  spoken.  Ordinary  jaun- 
dice may  last  for  a  period  varying  from  one  week  to  three  months. 
Probably  the  average  time  will  be  from  two  to  three  weeks.  When  it 
persists  for  more  than  a  month,  even  though  there  be  no  grave  symptoms, 
we  feel  some  degree  of  anxiety  lest  the  case  should  be  due  to  more  than 
a  temporary  obstruction  of  the  duct.  The  longest  case  of  ordinary  tem- 
porary jaundice  which  has  come  under  my  own  notice  lasted  for  upwards 
of  twelve  weeks.  For  the  whole  of  this  time  the  patient,  a  young  man 
of  eighteen,  was  deeply  jaundiced,  and  no  decided  improvement  began 
to  take  place  until  three  months  had  passed.  In  cases  where  the  malady 
is  prolonged  so  considerably  beyond  the  average  time,  we  may  suppose 
that  the  plug  of  mucus  or  modified  epithelium  in  the  common  duct  is 
firmer  than  usual.  At  last,  however,  the  mass,  having  become  softened, 


1 66  YELLOW  ATROPHY  OF  THE  LIVER. 

slowly  escapes,  bit  by  bit,  from  the  orifice  of  the  duct,  and  gradually 
the  organ  returns  to  its  normal  state. 

That  form  of  jaundice  which  is  very  fatal,  and  which  may  end  quickly 
in  death,  is  dependent  upon  serious  damage  to  the  secreting  and  other 
structures  of  the  liver,  and  the  liver-cells  are  often  completely  disinte- 
grated and  destroyed.  As  I  said  before,  I  do  not  know  how  we  can  dis- 
tinguish the  terribly  serious  from  the  slight  ailment  when  the  patient  first 
becomes  jaundiced.  In  the  fatal  form  of  jaundice,  however,  very  grave 
symptoms  are  developed  after  the  lapse  of  a  few  days,  and  we  then  become 
aware  of  the  terrible  disease  with  which  we  have  to  deal.  But  during  the 
first  few  days  of  the  attack  it  is,  I  believe,  not  possible  in  many  instances 
to  distinguish  a  case  which  will  end  fatally  from  a  case  which  will  termi- 
nate in  recovery.  I  allude  to  this  matter  because  it  is  really  most  impor- 
tant not  to  be  over-confident  and  off-hand  in  forming  a  prognosis  in  this, 
and  indeed  in  most  other  forms  of,  disease.  You  may  perhaps  be  called 
to  see  one  of  these  fatal  forms  of  jaundice,  due  to  what  has  been  called 
acute  yellow  atrophy  of  the  liver,  and,  if  nof  aware  of  the  existence  of 
such  cases,  you  might  make  a  very  sad  mistake  in  informing  the  friends 
confidently-thai  a  necessarily  fatal  disease  was  only  a  slight  ailment.  We 
ought  never  to  allow  ourselves  to  make  light  of  a  malady  which  may 
turn  out  to  be  very  serious  indeed.  Under  such  circumstances,  we 
might  be  deservedly  accused  of  want  of  care,  experience,  apd  knowl- 
edge, and  regarded  as  advisers  lacking  discretion  and  wisdom,  and  want- 
ing in  power  of  discerning  a  most  serious  disorder,  which  destroys  life 
in  a  short  time.  On  the  other  hand,  you  must  be  careful  not  to  need- 
lessly frighten  people  by  detailing  all  the  possibilities  of  disaster  in  any 
given  case.  Happily,  these  serious  forms  of  jaundice  are  not  common. 
In  the  course  of  a  year  we  seldom  see  in  the  hospital  more  than  one  or 
two  of  them,  and  several  years  may  pass  without  a  single  case  being 
admitted. 

Ordinary  temporary  jaundice  may  occur  at  any  period  of  life,  but  it 
is  most  common  between  the  ages  of  fifteen  and  twenty-four;  and  it  is 
more  frequently  met  with  in  males  than  in  females.  Whether  it  is  that 
we  are  apt  to  exceed  in  diet  more  than  the  other  sex  at  this  period  of 
life,  or  whether  the  way  we  live  has  anything  to  do  with  it,  I  cannot  tell ; 
possibly  we  maybe  more  anxious  and  nervous  about  our  work  and  exami- 
nations than  female  students;  but  it  is  certain  that  about  adolescence' 
jaundice  in  men  is  not  at  all  uncommon. 

Jaundice  occurring  in  middle  life  and  old  age  is  not  very  likely  to  be 
of  this  kind.  More  probably  it  will  depend  upon  some  more  serious 
change  than  catarrh  of  the  gill-ducts  and  the  obstruction  of  the  common 
duct  by  a  plug  of  mucus.  A  very  common  cause  of  jayndice  in  middle 
life  is  a  gall-stone  impacted  in  the  duct.  Jaundice  of  this  kind  is  usu- 
ally associated  with  great,  and  not  uncommonly  sudden,  excruciating  pain, 
and  its  nature  can  often  be  at  once  detected.  This  form  of  disease  can, 


SICK  HEADACHE.  l6/ 

however,  hardly  be  included  under  the  head  of  "slight  ailments."  You 
should  be  aware  that  jaundice  may  occur  in  very  young  children ;  and  I 
have  known  cases  in  which  it  existed  in  intra-uterine  life.  It  is  not  an 
uncommon  thing  for  the  child  at  birth  to  be  completely  jaundiced,  but 
this  usually  passes  off.  It  is  due  to  temporary  change.  I  have  seen  one 
case  in  which  life  was  destroyed  at  or  about  the  eight  month  of  intra- 
uterine  life  by  jaundice,  caused  by  the  impaction  of  a  gall-stone  in  the 
common  gall-duct.  What  is  the  earliest  period  of  development  at  which 
the  embryo  may  become  affected  I  cannot  say,  but  it  is  certain  that  some 
months  before  birth  biliary  calculi  may  be  formed.  Urinary  calculi  also 
may  be  produced  even  before  the  development  of  the  kidney  in  which 
they  are  formed  is  perfected. 

Treatment  of  Temporary  Jaundice. — With  regard  to  the  treatment  of 
ordinary  jaundice  there  is  little  to  be  said.  The  main  point  to  be  borne 
in  mind  is  that  the  patient  should  live  on  a  light  diet.  Do  not  let  him 
feed  heavily,  or  he  will  get  worse,  and  may  suffer  much.  Keep  the 
bowels  gently  acting  by  giving  small  doses  of  Blue  Pill  or-  Gray  Powder 
at  intervals  of  a  few  days.  You  may  also,  or  instead,  occasionally  give 
a  dose  of  some  saline  purgative.  A  drachm  or  two  of  Sulphate  of  Mag- 
nesia, Magnesia  Sulphas,  with  a  little  Hydrochloric  or  Sulphuric  Acid 
(p.  141)  before  breakfast,  is  of  service  in  this  condition,  just  to  promote 
the  action  of  the  bowels.  Do  not,  however,  give  violent  purgatives  or 
attempt  to  cure  the  disease  off-hand  by  any  course  of  special  treatment. 
A  mustard  poultice  may  be  placed  over  the  region  of  the  liver  every  day, 
or  every  other  day,  for  twenty  minutes.  Another  local  application  which 
seems  to  be  of  use,  and  which  I  learned  from  Dr.  Blakiston,  is  Hydro- 
chloric Acid  applied  on  rags.  The  strong  acid  is  diluted  with  twice 
its  bulk  of  water.  A  rag  is  carefully  wetted  with  the  lotion,  placed  over 
the  liver,  and  then  covered  with  some  useless  rags  or  an  old  towel.  This 
application  may  be  used  each  alternate  day,  care  being  taken  that  the 
acid  is  not  allowed  to  spoil  any  linen  or  the  clothes  of  the  patient.  It 
produces  only  a  little  tingling.  The  skin  should  be  wiped  with  a  soft, 
wet  sponge  when  the  rag  is  removed. 

I  come  now  to  another  malady,  reference  to  which  may  perhaps  raise 
a  smile.  It  is,  however,  an  extremely  disagreeable  ailment  to  endure, 
and  it  may  entirely  prevent,  or  seriously  mar,  the  execution  of  mental 

and  bodily  work. 

SICK   HEADACHE. 

This  is  one  of  the  most  severe  of  the  maladies  I  have  included  under 
the  head  of  slight  ailments.  The  affection  is  very  common,  and  used 
to  be  known  as  Migraine.  Some,  who  'in  other  respects  are  perfectly 
healthy  persons,  with  apparently  sound  constitutions,  and  whose  tissues 
generally  would  seem  to  be  not  only  healthy,  but  of  an  enduring  char- 
acter, suffer  from  very  frequent  attacks,  and  may  be  for  many  years 
hardly  ever  free  from  the  malady.  Nevertheless,  sick  headache  is  to  be 


1 68  NAUSEA  AND    VOMITING. 

regarded  as  a  very  troublesome  and  inconvenient,  rather  than  as  a  seri- 
ous, derangement. 

This  curious  disorder  may  affect  people  at  every  period  of  life.  Some 
authorities  assert  with  confidence  that  as  we  grow  older  we  overcome  the 
tendency  to  sick  headache ;  but  I  am  sorry  to  say  I  know  some  who  have 
grown  old,  and  many  who  are  growing  old,  who  still  suffer.  One  sees 
cases  of  sick  headache  occasionally  in  very  young  children,  frequently 
in  young  people  and  adults,  and  not  uncommonly  in  old  age.  I  know 
persons  of  seventy-five  and  upwards  who  continue  to  suffer  from  well- 
marked  forms  of  this  intractable  malady.  However,  there  is  no  doubt 
that  the  tendency  of  the  sick  headache  is  to  diminish  in  severity  as  age 
advances ;  so  that  many  who  are  martyrs  to  frequent  and  severe  attacks 
up  to  the  age  of  twenty-five  or  thirty,  begin  to  improve  after  that  period, 
and  towards  forty  become  troubled  less  frequently,  or  recover  altogether. 
In  others,  the  attacks  become  rare,  but  occur  now  and  then  as  long  as 
life  lasts. 

Sick  headache  is  a  disease  not  dependent  upon  any  actual  pathological 
change,  as  far  as  can  be  at  present  ascertained.  It  seems  to  be  due  to 
some  temporary,  but  widely-extended,  derangement,  influencing  a  number 
of  different  tissues  and  organs,  situated  at  a  distance  from  one  another. 

I  shall  endeavor  to  lay  before  you  the  several  phenomena  of  which  this 
malady  is  composed,  and  shall  try  to  point  out  in  what  respects  there  is 
a  departure  from  the  normal  and  healthy  action  of  the  several  organs  and 
tissues  involved.  In  the  first  place,  as  to  the  headache.  This  is  peculiar, 
for  it  is  usually  confined  to  one-half  or  less  of  the  head,  Hemicrania 
(^icrnf,  half,  upaviov,  the  head).  A  part  of  one  lateral  half  of  the  upper 
part  of  the  head  is  the  seat  of  very  severe  pain,  which  is  occasionally 
described  as  of  a  boring  or  penetrating  character,  and  may  be  so  circum- 
scribed that  the  painful  spot  could  be  covered  by  the  top  of  the  thumb. 
Sometimes  the  pain  is  situated  immediately  over  one  brow,  the  sensation 
experienced  being  like  that  which  would  be  produced  if  a  sharp  and 
strong  instrument  was  being  forced  into  the  head  at  that  particular  spot. 
The  pain,  varying  much  in  intensity,  and  somewhat  in  character,  from 
time  to  time,  may  last  for  a  period  of  from  twelve  to  twenty-four  hours, 
or  even  longer.  It  may  then  shift  to  the  opposite  side,  and,  after  lasting 
there  for  about  twelve  hours  more,  may  gradually  subside,  until  the  patient 
becomes  perfectly  free  from  pain.  In  a  short  time  he  feels  well,  and, 
perhaps,  for  some  days  after  the  attack  has  subsided  considers  himself 
unusually  vigorous.  From  the  frequency  of  the  occurrence  of  cases  in 
which  the  pain  is  confined  to  the  region  above  one  or  other  brow,  the 
condition  has  been  called  Broiv  Ague.  The  term  ague  is,  however, 
unfortunate,  for  the  affection  is  far  removed  from  maladies  belonging  to 
that  class. 

Next,  as  regards  nausea  and  vomiting,  which  frequently  accompany 
this  headache.  The  stomach  derangement  in  sick  headache  is  often  very 


NAUSEA   AND    VOMITING.  169 

marked  and  very  distressing;  but  these  symptoms  are  often  preceded  by 
an  almost  irrepressible  tendency  to  yawn  at  frequent  intervals.  There 
is  a  sensation  apparently  situated  in  the  soft  palate  which  almost  makes 
the  person  yield ;  but  as  soon  as  he  has  yawned  once  the  desire  returns; 
and  this  often  lasts  for  some  hours,  or  until  vomiting  occurs  or  sleep  is 
induced.  There  is,  as  I  have  said,  almost  always  more  or  less  nausea, 
and  not  unfrequently  absolute  vomiting,  the  depression  accompanying 
the  sickness  being  sometimes  of  the  most  distressing  character.  It  is 
often  as  bad  as  severe  sea-sickness.  I  have  known  people  to  vomit  fifteen 
or  twenty  times  in  the  course  of  the  day,  although  they  were  merely 
suffering  from  what  is  called  sick  headache.  In  this  condition,  then,  we 
have  temporary,  but  very  decided,  and  sometimes  violent,  disturbance 
of  the  digestive  organs,  inability  to  take  food,  nausea,  and  severe  vomit- 
ing, associated  with  pain,  more  or  less  acute,  on  one  side  of,  or,  it  may 
be,  all  over,  the  head.  The  vomiting  is  remarkable ;  for  there  is  not 
merely  straining  and  contraction  of  the  stomach,  followed  by  the  rejection 
of  its  contents,  but  a  great  deal  of  secretion  is  poured  into  the  stomach 
from  the  blood  or  from  the  glands;  and  after  this  has  accumulated  so  as 
to  distend  the  organ,  it  is  suddenly  expelled.  It  is  in  this  way  that  many 
of  those  who  suffer  from  sick  headache  get  relief.  After  the  removal  of 
the  contents  of  the  stomach,  which  are  often  of  an  intensely  acid  reaction, 
the  distressing  nausea  and  sense  of  oppression  and  exhaustion  become 
relieved  for  a  time,  but  recur  if  more  acid  fluid  is  poured  out.  What  is 
very  remarkable  in  many  of  these  cases  is  this :  that  food  may  be  digested 
shortly  before  the  vomiting  is  excited,  when  an  enormous  quantity  of  acid 
fluid  from  the  stomach  is  brought  up.  There  can  be  no  doubt  that  in 
these  cases  much  acid  is  formed  in  the  stomach,  or  secreted  by  the  glands. 
Indeed,  at  the  very  time  food  is  being  digested  and  passed  onwards  to 
the  duodenum,  there  is  evidence  of  the  formation  of  other  acids  beside 
the  ordinary  acid  of  the  gastric  juice.  Oxalic,  butyric,  acetic,  valerianic, 
are  among  the  organic  acids  which  are  developed,  owing  to  some  unusual 
chemical  changes  taking  place  in  the  contents  of  the  stomach.  It  is  the 
accumulation  of  this  acid  mixture  which  causes  the  nausea  and  painful 
sinking  experienced  at  the  pit  of  the  stomach.  The  nausea  remains  until 
the  contents  of  the  stomach  have  been  expelled.  Vomiting  may,  of 
course,  be  encouraged  by  the  administration  of  a  medicinal  emetic,  by 
drinking  several  tumblers  of  warm  water,  or  by  tickling  the  back  of  the 
fauces.  The  act  of  vomiting  may  be  attended  with  instant  relief.  I  have 
known  cases  in  which,  the  moment  after  the  stomach  had  rejected  its 
contents,  the  pains  ceased,  and,  for  a  time  at  least,  the  patient  is  in 
comparative  ease,  or  feels  perfectly  well. 

In  slight  sick  headache,  as  well  as  in  more  serious  head  affections, 
there  is  evidence  of  remarkable  sympathy  and  association  between  the 
action  of  the  brain  and  the  stomach.  The  pain  that  we  suffer  in  sick 
headache  is  not  due  merely  to  some  affection  of  the  cutaneous  nerves 


I/O  DERANGEMENT  OF  THE  STOMACH. 

of  the  skin  of  the  head  and  face,  as  has  been  held  by  some,  but  there  is 
clearly  a  temporary  disturbance  in  the  brain  itself,  probably  in  connec- 
tion with  the  vessels  at  least  of  the  surface  of  the  gray  matter  of  the  con- 
volutions, for  not  only  does  the  pain  seem  to  be  situated  in  the  brain, 
but  the  action  of  the  cerebral  matter  is  unmistakably  disturbed.  The 
memory  is  for  the  time  impaired.  Attention  cannot  be  given  without 
conscious  and  even  painful  effort.  Sustained  thought  is  impossible  for 
the  time,  and  there  is  a  decided  longing  for  mental  rest,  which,  being 
yielded  to,  soon  results  in  dozing,  or  in  actual  sleep.  It  might  be 
thought  that  cerebral  disturbance  generally,  at  least  when  ushered  in  by 
functional  or  organic  disease  of  the  digestive  organs,  would  be  due  to 
deranged  action  of  the  upper  part  of  the  alimentary  canal  only.  The 
most  remarkable  phenomena  undoubtedly  point  to  stomach  and  duodenal 
disturbance,  and  we  know  that  in  many  diseases  of  the  brain  the  action 
of  the  stomach  especially  is  disturbed — frequent  and  sudden  vomiting 
being  often  present.  The  action  of  the  stomach,  as  every  one  has  expe- 
rienced, is  much  influenced  by  the  brain,  and  the  latter  by  the  stomach. 
Digestion  may  seriously  derange  cerebral  action,  and  may  in  its  turn  be 
modified  or  completely  interfered  with  by  mental  or  emotional  disturb- 
ance. This  indeed  is  admitted,  but  in  many  forms  of  sick  headache  the 
derangement  is  certainly  more  general  than  the  consideration  of  the  sub- 
ject thus  far  would  have  perhaps  led  you  to  suppose,  and  it  is  doubtful 
whether  the  lower,  as  well  as  the  upper,  part,  and  in  some  cases  exclu- 
sively the  lower  part,  of  the  alimentary  canal  is  not  implicated  in  the 
attack.  I  shall  presently  refer  to  this  point  more  particularly. 

The  disturbance  of  the  nervous  system  in  sick  headache  is  so  striking 
and  widespread,  that  some  pathologists  have  been  induced  to  place  sick 
headache  among  nervous  diseases,  and  to  support  the  conclusion  that  the 
derangement  not  only  begins  in  the  nervous  system,  but  that  the  affection 
is  exclusively  nervous.  To  me,  however,  it  seems  more  probable,  and 
the  conclusion  is  grounded  partly  upon  personal  experience,  that  the 
nerve  phenomena  are  second  in  the  order  of  their  occurrence,  and  that 
the  starting-point  of  the  malady  is  abnormal  functional  disturbance  in 
the  digestive  organs,  and,  through  these,  in  the  blood  itself. 

That  the  blood  is  deranged  in  cases  of  sick  headache  is  probable  from 
several  circumstances.  It  has  been  noticed  that  any  wound  or  scratch 
that  there  may  be  on  the  surface  of  the  skin  looks  angry.  The  processes 
of  healing  and  the  nourishment  of  tissues  do  not  proceed  as  in  perfect 
health.  Another  reason  for  concluding  that  the  blood  is  more  or  less 
out  of  order  is  that,  when  the  sick  headache  disappears,  very  free  action 
of  excretory  glands  sets  in.  A  considerable  quantity  of  urine,  often  rich 
in  uria  and  urates,  and  of  high  specific  gravity,  is  voided,  and  this  is  suc- 
ceeded by  the  free  secretion  of  large  quantities  of  pale  urine  containing 
a  small  proportion  of  solid  matter.  Gradually  the  ordinary -actions  in 
the  several  tissues  and  organs  are  resumed. 


DERANGEMENT  OF  THE  LARGE  BOWEL.  I?  I 

The  composition  of  the  blood  is  also  much  altered  during  the  attack 
by  the  free  discharge  of  certain  substances  from  it  into  the  stomach. 
The  glands,  instead  of  pouring  out  ordinary  gastric  juice  to  digest  the 
food,  secrete,  and  in  considerable  quantity,  a  fluid  which,  instead  of  qui- 
etly digesting  the  food,  irritates  the  nerves  distributed  to  the  mucous 
membrane,  and  causes  vomiting.  The  fluid  is  frequently  highly  acid, 
but,  as  I  have  remarked,  the  acidity  is  due  to  a  number  of  organic  acids 
which  are  not  to  be  found  in  health.  Under  these  circumstances  it  is 
useless  to  introduce  food  into  the  stomach, -for  little  or  no  digestion  will 
take  place.  The  stomach  must  be  allowed  to  rest  for  a  while,  until  its 
contents  are  rejected,  or  by  degrees  driven  downwards  into  the  small 
intestine.  It  seems,  then,  probable  that  certain  materials  which  yield 
these  substances  when  discharged  into  the  stomach  have  been  accumu- 
lating in  the  blood  for  some  time  before  the  attack  of  sick  headache 
occurs — that,  indeed,  the  malady  depends  upon  this  accumulation  in  the 
blood,  and  that  the  "attack"  corresponds  to  their  discharge  into  the 
stomach. 

The  salivary  glands,  the  little  labial  and  buccal  glands,  are  elso  affected. 
Saliva  is  very  sparingly  secreted,  and  the  mouth  is  often  in  a  dry  or  clammy 
and  uncomfortable  state;  the  mucous  membrane  dries  very  quickly;  there 
is  often  a  very  unpleasant  taste,  and  instead  of  the  mucous  surface  being 
soft  and  moist,  it  seems  to  be  besmeared  with  viscid  mucus,  and  the 
patient  will  tell  you  his  mouth  is  quite  out  of  order.  In  many  cases 
the  action  of  the  salivary  glands  is  certainly  suspended  for  a  time,  and 
when  the  attack  is  passing  off,  one  of  the  first  points  noticed  is  the 
pouring  of  a  quantity  of  saliva  into  the  mouth.  With  the  return  of 
salivary  secretion,  the  unpleasant  sensations  about  the  mouth,  the  dry- 
ness,  the  disagreeable  taste,  and  the  clamminess  disappear. 

The  liver  is  out  of  order  in  "sick  headache."  Its  action  in  many 
cases  seems  indeed  to  be  almost  suspended  for  a  time.  The  excrements 
are  sometimes,  but  not  invariably,  pale  and  altered  in  consistence.  The 
intestine  is  not  stimulated  to  perform  its  ordinary  contractions,  and  in 
many  cases  flatus  collects.  Moreover  the  surface  of  the  liver  is  some- 
times tender  to  the  touch.  Not  unfrequently  there  is  a  feeling  of  fulness 
or  actual  pain  in  the  right  side;  and  often  there  is  distinct  yellowness 
of  the  skin  and  the  conjunctiva.  The  action  of  the  alimentary  canal  is 
partially  suspended,  or  the  intestine  scarcely  acts  at  all.  Its  contents,  in 
many  instances,  seem  to  remain  almost  still  for  a  time  during  the  attack, 
or  are  very  slowly  urged  towards  the  lower  bowel.  The  action  of  the 
colon  is  suspended.  No  accumulation  of  faecal  matter  goes  on  during 
the  attack,  for  faeces  are  at  the  time  not  being  formed. 

In  some  cases  of  sick  headache,  I  think  the  derangement  actually  begins 
in  the  large  intestine.  Sometimes  there  is  evidence  of  moderate,  but  not 
excessive,  faecal  accumulation,  with  a  passive  state  of  the  mucous  membrane 
and  its  glands,  and  sluggishness  of  its  muscular  coat.  The  caecum  and 


1^2  MEMORY  AND    TEMPER. 

ascending  colon  are  very  commonly  at  fault ;  and  I  have  often  succeeded 
in  feeling  the  accumulation  at  this  part  of  the  bowel.  The  patient  him- 
self is  frequently  aware  of  some  discomfort  or  unpleasant  sensation  in  the 
right  iliac  fossa.  By  palpation  you  may  detect  the  fulness,  and  by  the 
tympanitic  percussion  over  this  part  of  the  bowel  you  demonstrate  the 
presence  of  gas,  much  of  which  probably  arises  from  decomposition  of 
materials  which  ought  to  have  been  expelled  long  before.  It  does  not 
follow  that  actual  constipation  has  prevailed,  but  the  bowel  has  not  com- 
pletely emptied  itself.  For  -some  time,  perhaps  for  weeks  and  months, 
it  has  not  driven  down  the  fsecal  matter  towards  the  rectum  as  fast  as  it 
was  formed.  The  lower  part  of  the  ileum,  as  well  as  the  caecum,  is  at 
fault  in  many  instances.  Probably  Peyer's  patches  and  the  solitary  glands 
do  not  act  freely;  and  oftentimes  their  action  is  further  disturbed  by  the 
constant  presence  of  faulty  secretion,  and  possibly  of  the  products  of 
fermentation  and  unusual  chemical  action  in  the  slowly-moving  and 
almost  putrefying  mass.  The  action  of  the  glands  themselves  is  then 
interfered  with;  and  the  uneasiness  and  pain  which  are  sometimes  ex- 
perienced may  be  due  to  this  cause.  You  must  not  forget  these  points, 
for  they  are  of  interest  in  connection  with  the  causation  of  many  derange- 
ments of  the  health,  some  of  which  are  by  no  means  slight.  I  believe 
that  a  prolonged,  and  perhaps  almost  constantly  disturbed,  action  of  this 
part  of  the  alimentary  canal  leads  to  important  changes  in  the  blood,  and 
may  establish  a  state  of  system  favorable  to  the  development  of  important 
diseases  of  different  kinds.  Neither  must  it  be  forgotten  that  when  mate- 
rials remain  for  some  time  in  contact  with  the  mucous  membrane  of  the 
large  bowel,  reabsorption  occurs,  and  thus  many  noxious  matters,  which 
ought  to  be  discharged  from  the  system,  find  their  way  in  an  objectionable 
form  into  the  blood. 

You  see,  then,  in  sick  headache  there  is  evidence  of  very  widespread, 
but,  at  the  same  time,  slight,  derangement  in  many  organs  and  tissues  of 
the  body.  There  is  general  disturbance  of  the  intestinal  canal,  alterations 
in  the  composition  of  the  blood,  and  disturbed  action  of  many  parts  of 
the  nervous  system.  There  are  derangements  of  touch,  perverted  taste 
and  smell,  often  disturbance  connected  with  vision,  and,  not  unfrequently, 
singing  in  the  ears,  and  other  departures  from  the  normal  state  as  regards 
the  action  of  the  organ  of  hearing.  The  action  of  the  heart  is  depressed. 
The  capillary  circulation  is  deranged,  there  being  too  little  blood  in  some 
parts,  congestion  in  others.  Digestion  is  much  deranged,  and  the  action 
of  the  liver  and  other  secreting  organs  is  seriously  impaired  for  the  time. 
The  muscles  do  not  work  as  they  should  do.  Delicate  movements  cannot 
be  executed  with  the  usual  precision,  and  sustained  muscular  effort  is 
difficult  or  impossible.  The  body  is  fatigued.  The  memory  is  more 
or  less  affected  for  a  time,  and  in  many  instances  the  temper  becomes 
"  bilious."  To  attempt  brain-work  when  you  suffer  from  sick  headache 
would  be  useless,  for  the  mind  will  not  work  to  any  advantage.  Some- 


SICK  HEADACHE  AND  EPILEPSY.  173 

times  there  is  a  very  distressing  faintness,  and  a  feeling  of  terrible 
exhaustion ;  the  heart's  action  being  often  very  feeble  for  a  time,  and 
sometimes  so  very  weak  as  to  cause  alarm.  Rest  in  the  recumbent  posture 
for  a  few  hours  may  be  necessary ;  but,  generally,  the  heart  soon  regains 
its  usual  power  if  let  alone.  Stimulants  sometimes  increase  the  stomach 
disturbance,  and  prolong  the  attack;  but  if  the  heart's  action  is  very 
depressed  it  may  be  desirable  to  administer  Ammonia  or  brandy,  in  very 
small  quantities,  at  short  intervals,  until  the  organ  regains  its  natural 
strength,  as  indicated  by  the  character  and  intensity  of  the  heart's  sounds. 

When  the  attack  of  sick  headache  begins  to  pass  off,  urine,  often  loaded 
with  deposits  of  Urates  of  Soda,  Ammonia,  and  Lime,  and  of  high  specific 
gravity,  is  excreted.  Then  the  kidneys  begin  to  act  freely;  the  bowels 
also  act  slightly,  and  in  a  few  hours  more  the  patient  will  feel  well.  It 
is  remarkable  that,  after  all  this  disturbance  in  the  system,  the  individual 
who  has  suffered  should  be  for  a  time  in  better  health  than  usual;  and 
he  may  feel  exceptionally  well  and  vigorous.  Indeed,  you  will  find  that 
many  of  the  victims  of  this  derangement  have  considerable  powers  of 
endurance,  which  enable  them  in  a  great  many  instances  to  work  on 
energetically,  far  into  old  age.  Many  who  suffer  severely,  though  not 
fit  to  work,  by  great  effort  may  get  through  their  duties,  and,  perhaps, 
during  a  long  lifetime  may  not  have  been  forced  to  absent  themselves 
for  a  single  day.  As  far  as  I  know,  no  harm  results  from  working  on 
through  a  sick  headache,  in  cases  in  which  this  can  be  done,  but,  of 
course,  certain  kinds  of  work  cannot  possibly  be  executed  under  the 
circumstances.  Attacks  of  sick  headache  may  occur  once  a  week  and 
oftener,  or  the  affection  may  recur  not  oftener  than  once  in  a  fortnight, 
or  once- a  month,  or  still  less  frequently.  You  will  sometimes  find  that 
the  suffering  returns  almost  to  the  day,  after  a  week  or  a  fortnight,  or 
other  interval. 

In  spite  of  this  almost  continual  disorder,  the  general  phenomena  of 
the  system,  essential  to  the  continuance  of  life,  proceed  as  usual.  I  think 
that  some  of  those  who  surfer,  and  who  take  moderate  care  of  themselves, 
really  enjoy  certain  advantages  as  regards  the  prospect  of  longevity. 
Their  tissues  do  not  seem  to  grow  old  as  fast  as  those  of  many  of  their 
more  vigorous  contemporaries.  Periodical  sick  headaches  may,  after  all, 
be  conservative  in  their  action,  and  may  protect  the  organism  from  more 
serious  pathological  derangements,  thus  perhaps  enabling  persons  to  live 
long  who  might  under  other  circumstances  die  early.  Although  the 
digestive  organs  may  be  seriously  wrong  for  a  certain  time,  they  get  the 
advantage  of  resting  from  time  to  time  for  periods  varying  from  twelve 
to  twenty-four  hours.  If  in  the  affected  organism  anything  happens  to 
be  wrong  in  connection  with  the  alimentary  canal,  there  is  the  advantage 
of  time  being  allowed  for  the  derangement  to  right  itself  instead  of  per- 
sisting until  actual  morbid  change  has  resulted.  There  appears  to  be 
hyper-sensitiveness  in  connection  with  the  nerves  of  the  digestive  organs 
15* 


174  NEUROSES  AND  NERVE  STORMS. 

in  many  who  suffer  from  sick  headache,  which,  by  favoring  severe  tem- 
porary disturbance  of  a  functional  character,  may  prevent  damage  and 
permanent  structural  changes  in  important  tissues.  Possibly  this  may  be 
the  reason  why  many  people  who  suffer  from  sick  headache  not  only  live 
to  be  old,  but  retain  their  vigor  in  old  age. 

Some  physicians  have  thought  that  an  intimate  relationship  existed 
between  sick  headache  and  the  epileptic  state,  but  we  meet  with  so  many 
instances  of  each  condition  without  the  slightest  indication  of  tendency 
to  the  other,  that  I  cannot,  without  some  further  evidence,  accept  this 
opinion  as  correct.  Undoubtedly  you  will  now  and  then  meet  with  a 
case  which  might  seem  to  justify  such  an  inference,  but  you  will  also 
come  across  cases  which,  considered  alone,  might  suggest  a  relationship 
between  epilepsy  and  many  other  forms  of  disease  usually  considered 
quite  distinct.  Indeed,  there  are  few  morbid  conditions  in  which  nerve 
derangement  exists  which  might  not  be  adduced  as  supporting  the  view 
of  their  affinity  to  the  epileptic  state.  Hysteria,  nightmare,  waking  up 
suddenly  in  the  night  and  calling  out,  nocturnal  expulsion  of  urine, 
twitchings  occurring  in  the  muscles,  may  all  be  regarded  as  belonging  to 
the  category  of  epileptic  affections.'  But  if  I  admitted  this  view  to  be 
probably  correct,  I  should  still  be  disposed  to  doubt  whether  any  con- 
nection between  sick  headache  and  any  form  of  the  epileptic  state  had 
been  proved  to  exist.  Some  cases  that  come  under  our  notice  would 
seem  to  justify  the  notion  that,  in  certain  instances,  attacks  of  sick  head- 
ache take  the  place  of  attacks  of  gout,  and  that  the  two  affections  are 
related.  But  it  must  be  admitted  that  there  are  many  persons  who  suffer 
from  sick  headache  who  have  no  tendency  to  gout,  while  many  who  have 
gout  hardly  know  what  it  is  to  suffer  from  headache  of  any  kind.  Nev- 
ertheless, there  is  reason  to  think  that  in  both  affections  the  blood  is 
deranged,  and  possibly  by  the  accumulation  in  it  of  nitrogenous  mate- 
rials which  ought  to  be  eliminated.  Both  affections  come  on  at  inter- 
vals, and  often  suddenly.  Both  are  relieved  by  the  same  general  treat- 
ment. Both  are  aggravated  by  a  full  meat  diet,  and  mitigated  by  a  diet 
largely  composed  of  vegetables  and  fruit.  In  both  there  is  derangement 
of  the  liver,  and  Calomel  and  other  remedies  which  act  upon  that  and 
other  excreting  organs  relieve  those  who  suffer  from  gout  as  well  as  those 
who  suffer  from  sick  headache. 

We  cannot,  I  think,  accept  the  generalization  that  sick  headache 
belongs  to  the  class  of  neuralgic  affections ;  for  those  who  suffer  from 
severe  forms  of  neuralgia  do  not  seem  to  be  more  susceptible  of  sick 
headache  than  other  persons ;  nor,  on  the  other  hand,  are  the  victims  of 
sick  headache  unusually  prone  to  neuralgic  pains.  I  do  not  see  what 
we  gain  by  calling  this,  and  many  diseases  in  which  nerves  are  affected, 
"  neuroses,"  or  by  referring  them  to  "  nerve  storms,"  for  no  one  knows 
what  he  means  by  the  phrase  "nerve  storm."  Nor  has  the  supposed 
conr.ection  between  sick  headache  and  ague,  and  maladies  of  that  class 


TREATMENT  OF  SICK  HEADACHE.  175 

been  proved.  There  seems  to  be  an  alliance  between  many  different 
diseases,  but  it  is  most  difficult  to  do  more  than  point  out  the  connec- 
tion in  general  .terms.  As  time  goes  on,  I  have  no  doubt  many  affections 
which  have  received  different  names,  and  are  now  regarded  as  distinct 
diseases,  will  be  shown  to  be  much  more  closely  related  to  one  another 
than  we  should  be  led  to  suppose  from  the  accounts  given  in  our  system- 
atic works  on  medicine.  For  reasons  to  which  I  have  already  adverted, 
I  should  rather  place  ordinary  sick  headache  under  the  head  of  derange- 
ments of  the  digestive  organs  than  include  it  in  the  disorders  of  the 
nervous  system.  This  question  of  the  nature  of  the  malady  has  an 
important  practical  bearing,  for  it  must  influence  our  views  as  regards 
treatment.  Now  I  think  I  may  go  so  far  as  to  commit  myself  to  the 
opinion,  that  if  the  digestive  system  and  the  most  important  organs  of 
excretion  could  be  made  to  work  properly,  and  could  be  kept  working 
properly,  the  subjects  of  sick  headache  would  be  cured,  and,  from  the 
time  when  these  results  had  been  obtained,  would  be  free  from  attacks. 

It  appears  to  me  probable,  for  reasons  which  I  have  set  forth,  that 
some  material  gradually  accumulates  in  the  blood,  and  by  its  deleterious 
action  on  the  nerve-cells  of  the  brain  gives  rise  to  the  headache,  and 
causes  the  inability  to  think,  or  at  any  rate  renders  it  impossible  to  sus- 
tain connected,  thought  for  many  minutes  at  a  time.  This  inability  to 
think  is  probably  caused  by  an  indirect  action  leading  to  dilatation  of  the 
capillaries  of  the  pia  mater  and  those  in  the  superficial  part  of  the  gray 
matter  of  the  convolutions.  At  the  same  time  it  is  probable  that  the 
fluid  effused  from  these  vessels,  laden  with  matters  which  ought  to  have 
been  eliminated,  bathes  the  nerve-cells,  and  exerts  a  deleterious  influence 
upon  them.  A  small  dose  of  Calomel  within  two  hours,  or  even  less 
time,  completely  alters  the  state  of  things — for  the  nausea,  the  headache, 
the  misty  confusion  of  intellect,  all  disappear.  The  kidneys  soon  begin 
to  secrete  actively,  and  in  this  way  the  blood  is  depurated.  The  stom- 
ach and  the  intestinal  canal  participate,  and  then  the  peccant  matter 
which  has  accumulated  is  removed  and  the  healthy  function  restored. 

Treatment  of  Sick  Headache. — I  believe  we  may  often  succeed,  by 
judicious  management,  in  reducing  the  number  and  severity  of  the  at- 
tacks of  this  disorder.  You  must,  in  the  first  place,  inquire  very  minutely 
into  the  general  habits  of  the  patient,  and,  of  course,  advise  him  to  correct 
any  irregularities  he  may  have  committed  as  regards  quantity  and  quality 
of  food,  and  the  times  of  taking  it.  To  lay  down  a  strict  dietary  is, 
however,  useless,  nay,  it  might  be  mischievous,  and  more  harm  than 
good  result.  Many  doctors  make  themselves  ridiculous,  and  their  patients 
miserable,  by  the  absurd  importance  they  attach  to  severe  restrictions 
as  regards  particular  articles  of  diet.  The  victim  of  sick  headache  will 
not  gain  anything  by  feeding  as  if  he  was  in  prison,  and  exercising  as  if 
he  were  under  sentence  of  penal  servitude,  or  undergoing  the  "  cure  "  at 
some  strict  German  bathing  establishment.  You  may  cut  off  his  beer, 


i;6  TREATMENT  OF  SICK  HEADACHE. 

wine,  and  all  things  containing  sugar;  you  may  order  him  to  take  so 
many  pieces  of  dry  toast  at  breakfast,  without  a  particle  of  butter,  and 
only  allow  him  skim  milk  and  lime-water  to  drink.  You  may  limit  him 
to  a  biscuit  for  lunch,  and  allow  a  small  chop,  with  bread  pudding,  made 
without  any  sugar,  for  dinner,  and  a  cup  of  water  arrow-root  for  supper, 
or  no  supper  at  all.  You  may  make  him  walk  so  many  measured  miles, 
rise  at  a  certain  hour,  and  retire  at  a  time  when  most  people  consider 
the  hour  for  a  little  quiet  reading  or  other  harmless  enjoyment  has 
arrived,  and  all  to  no  purpose ;  nay,  instead  of  getting  better,  he  may 
tell  you  that  he  is  worse,  and  feels  less  happy  and  contented  than  before, 
and  less  able  to  be^tr  his  suffering.  Your  advice,  as  regards  living,  should 
be  considerate,  but  not  too  strict ;  for,  in  the  first  place,  we  do  not  know 
enough  about  the  real  nature  of  the  malady  to  justify  us  in  accurately  and 
arbitrarily  laying  down  the  law  of  living  ;  and,  secondly,  experience  has 
incontestably  proved  that  persons  who  suffer  from  sick  headache  get  on 
better,  upon  the  whole,  if  they  live  fairly  well  in  the  intervals,  and  starve 
for  the  short  period  during  which  they  have  to  suffer.  As  regards  wine, 
it  will  be  generally  found  that  light  wines,  such  as  hock,  suit  the  sufferers, 
if  they  require  stimulants  at  all ;  but  many  who  suffer  from  the  malady 
do  not  require  any  form  of  alcohol  whatever. 

There  are  many  cases  of  sick  headache  that  have  resisted  every  attempt 
to  cure  them;  indeed,  it  must  be  confessed  that,  up  to  this  time,  no 
certain  method  of  "cure"  has  been  discovered.  While  the  headache 
lasts,  and  the  action  of  the  stomach  and  liver,  and,  indeed,  of  the  secret- 
ing organs  generally,  is  suspended,  even  the  most  digestible  substances 
do  harm,  and  I  know  of  no  medicine  that  invariably  affords  relief  to  the 
patient. 

Some  of  those  who  suffer  from  this  unpleasant  affection  can  tell,  some 
days  before  the  derangement  begins,  that  they  are  about  to  have  an 
attack.  There  is  a  disagreeable  taste  in  the  mouth,  with  a  degree  of 
dryness,  particularly  at  the  tip  of  the  tongue ;  a  feeling  of  distention  or 
fulness  over  the  stomach  ;  sluggishness  or  inaction  of  the  bowels ;  lassi- 
tude, and  an  indisposition  to  take  active  exercise  ;  slight  or  considerable 
depression  of  spirits,  and  an  inclination  to  sleep.  The  appetite  may  still 
be  good  ;  but  there  is  often  some  degree  of  discomfort  after  taking  food, 
and  very  frequently  a  feeling  of  regret  that  anything  in  the  shape  of  food 
had  been  taken  at  the  time.  Now,  if  the  patient,  by  whom  the  import 
of  these  premonitory  symptoms  is  understood,  takes  two  or  three  grains, 
or  even  one  grain,  of  Gray  Powder,  with  a  little  Colocynth,  and,  perhaps, 
a  saline  draught  the  following  morning,  he  may  completely  escape  the 
impending  attack.  He  may  feel  more  or  less  out  of  sorts  for  a  day  or 
two,  but  he  does  not  get  the  severe  headache,  and,  perhaps,  also  escapes 
the  sickness,  though  very  likely  he  experiences  a  slight  degree  of  nausea. 
This  surely  indicates  that  matters  which  had  accumulated  in  the  blood 
have  been  removed  by  the  purgative,  and  have  thus  been  prevented  from 


TREATMENT  OF  SICK  HEADACHE.  .       1?? 

exerting  a  deleterious  influence,  culminating  in  the  headache,  and  causing 
other,  symptoms. 

But  what  should  be  done  in  these  cases?  What  methods  of  treatment 
afford  the  best  chance  of  relieving  the  patient  who  actually  suffers?  If 
you  cannot  always  cure  the  patient  you  may  do  something  to  prolong 
the  interval  between  the  attacks,  and  to  mitigate  the  severity  of  symptoms 
when  they  occur.  If  the  sick  headache  is  not  severe,  persuade  the  patient 
to  think  as  little  about  it  as  possible.  Recommend  him  to  go  about  his 
ordinary  work,  and  tell  him  to  try  by  his  manner  to  prevent  people  from 
discovering  that  he  is  ill ;  for  too  much  sympathy  and  kind  inquiry  con- 
centrates his  attention  upon  the  malady,  and  makes  him  feel  worse.  If 
anything  appears  to  annoy  him,  he  should  keep  quiet,  and  restrain  him- 
self from  expressing  any  decided  opinion  until  he  is  well ;  otherwise  he 
may  get  the  character  of  being  a  very  ill-tempered  or  cantankerous  person, 
when,  in  truth,  he  is  nothing  of  the  sort.  It  is  his  headache,  not  himself, 
that  does  the  wrong. 

I.    TREATMENT   DURING   AN    ATTACK   OF   SICK  HEADACHE. 

Rest. — During  a  severe  attack  of  sick  headache,  the  patient,  if  this  be 
possible,  must  have  complete  rest,  so  that  the  organs  which  are  deranged 
may  be  allowed  to  gradually  right  themselves.  The  mind  and  the  ner- 
vous system  need  repose  as  well  as  the  stomach,  liver,  and  other  organs. 
When  the  suffering  is  very  great,  and  particularly  in  cases  in  which  there 
is  that  distressing  feeling  of  nausea,  and  frequent  or  occasional  attacks 
of  actual  vomiting,  the  patient  must  lie  down.  But  one  meets  with  many 
instances  in  which  he  is  able  to  continue  his  usual  avocation,  in  spite  of 
the  headache ;  and  I  am  not  aware  that  any  one  has  discovered  that  his 
sufferings  were  actually  greater,  or  lasted  longer,  than  when  he  adopted 
another  plan,  and  gave  way  as  soon  as  the  headache  came  on,  and  lay 
down  in  a  darkened  room  until  the  attack  passed  off.  In  bad  cases, 
however,  and  especially  if  the  patients  are  weak,  and  in  other  respects 
out  of  health,  absolute  rest  in  the  recumbent  posture  must  be  recom- 
mended from  the  commencement  of  each  attack. 

Starving  in  Sick  Headache. — The  patient  who  is  suffering  from  an 
attack  ought  to  starve  for  the  time,  and  thus  rest  the  stomach  until  the 
attack  passes  off.  It  is  very  remarkable  that  many  who  suffer  from  this 
troublesome  disorder  are  able  to  discharge  even  active  duties  without 
taking  any  food  at  all  for  perhaps  twenty-four  hours  or  longer,  although 
in  ordinary  health  the  same  person  would  get  completely  faint  if,  fasting, 
he  attempted  to  do  the  same  amount  of  work.  A  person  may  get  up 
with  a  sick  headache  and  be  quite  unable  to  eat  any  breakfast,  and  yet 
he  may  perform  the  ordinary  duties  of  the  day,  and  perhaps  continue 
working  up  to  nine  or  ten  o'clock  at  night  without  having  taken  a  par- 
ticle of  food,  and  yet  without  suffering.  The  same  man  in  his  ordinary 
health  might  not  be  able  to  postpone  breakfast  for  an  hour  without  feel- 
Id 


1/8  INFLUENCE   OF  WARMTH. 

ing  faint  and  exhausted.  This  peculiar  state  in  which  abstinence  from 
food  does  not  occasion  exhaustion  may  last  for  forty-eight  hours,  during 
which  period  not  an  ounce  of  solid  matter  may  be  taken,  and  yet  it  does 
not  follow  that  the  nutrition  of  the  body  will  be  in  any  way  impaired, 
or  the  health  damaged  for  any  length  of  time.  The  patient  will  not  lose 
in  weight,  because  the  organs  soon  resume  their  natural  functions.  When 
the  appetite  returns,  and  the  victim  is  able  to  eat  again,  plenty  of  nutri- 
ent material  will  be  poured  into  the  system  and  rapidly  appropriated. 
Abstention  from  food  for  twehty-four  hours  is  usually  long  enough  to 
allow  the  organs  which  are  deranged  to  right  themselves.  But  in  any 
case  during  an  attack  of  sick  headache,  it  is  not  of  the  slightest  use  to 
attempt  to  force  the  patient  to  eat.  Even  bread  and  butter  is  apt  to  dis- 
agree. The  starchy  matter  of  the  bread  instead  of  being  digested  is  apt 
to  undergo  other  changes,  and  butter  and  other  fats  suffer  decomposition, 
various  organic  acids  being  formed,  which,  after  a  time,  irritate  the 
stomach,  and  cause  it  to  reject  its  contents.  Even  meat  is  not  digested, 
but  if  the  patient  feel  exhausted,  a  little  cold  beef-tea  may  be  absorbed, 
or  beef-tea  which  has  been  artificially  half  digested  with  the  acid  of 
pepsine,  p.  no.  If  patients  object  to  starve  from  the  fear  that  they 
will  get  very  weak,  you  may  tell  them  to  try  a  little  mutton  broth  or 
beef-tea,  which  should  be  entirely  free  from  fat,  and  should  be  sipped. 
Of  course,  as  far  as  any  real  advantage  is  concerned,  they  might  just  as 
well  take  nothing,  for  the  little  that  is  introduced  under  these  circum- 
stances cannot  in  any  way  help  nutrition,  although  it  may,  on  the  other 
hand,  somewhat  interfere  with  the  return  of  the  stomach  to  its  normal 
state.  The  fact  is,  that  temporary  abstinence  from  food,  as  above  sug- 
gested, can  do  no  harm  whatever,  and  this  course  is  necessary  if  the 
patient  desires  to  gain  his  normal  state  of  health  in  the  shortest  time 
possible,  and  with  the  least  degree  of  suffering. 

Warmth. — Exposure  to  cold  often  precipitates  an  attack  of  sick  head- 
ache if  one  is  about  to  come  on.  Indeed,  many  sufferers  attribute  the 
illness  to  the  direct  influence  of  cold.  I  have  thought  on  some  occasions 
that  instead  of  catching  an  ordinary  cold  from  undue  exposure,  I  had 
contracted  the  greater,  if  less  lasting  suffering, — sick  headache.  Sick 
headache  is  certainly  relieved  by  warmth.  A  warm  bath  sometimes 
removes,  the  headache,  and  almost  always  gives  relief  for  the  time.  In 
slight  attacks  of  sick  headache  complete  relief  may  be  obtained  by  put- 
ting the  feet  into  hot  water,  or  even  by  simply  well  warming  them  before 
a  good  fire.  An  ordinary  hot-water  bottle,  or,  better,  a  vulcanized  India- 
rubber  bottle  filled  with  hot  water  and  applied  to  the  stomach,  some- 
times appears  to  be  of  use,  and  is  at  any  rate  very  pleasant  under  the 
circumstances. 

Counter- Irritation. — There  is  no  doubt  whatever  that  considerable 
temporary  relief  is  afforded  during  an  attack  of  sick  headache  by  the 
employment  of  counter-irritants.  A  mustard  plaster  (half  mustard  and 


ADVANTAGE    OF  TEA-DRINKING.  1/9 

half  linseed)  to  the  back  of  the  neck  or  to  the  pit  of  the  stomach  will 
relieve  the  pain,  or  half  of  one  of  Rigollot's  mustard  leaves,  a  piece  of 
writing-paper  intervening  between  the  mustard  and  the  skin,  may  be 
applied  in  one  or  both  situations ;  but  one  of  the  best  applications  to 
be  used  in  these  cases  is  described  on  p.  97.  In  recommending  the 
external  application  of  strong  Hydrochloric  Acid,  you  must,  however, 
always  be  very  careful  to  give  explicit  directions,  or  you  will  get.  into 
great  disgrace  in  consequence  of  the  destruction  of  bed-clothes  and  the 
serious  damage  to  wearing  apparel. 

Acids. — It  is  curious  that  in  many  cases  in  which  acids  are  produced 
in  undue  proportion  by  decomposition  of  various  materials  in  the  stom- 
ach, there  should  be  a  natural  desire  for  things  having  an  acid  taste. 
Many  persons  certainly  experience  a  distinct  longing  for  acid  drinks, 
which  undoubtedly  afford  relief  in  some  cases.  Lemon  or  Lime  juice 
and  water  is  very  grateful  to  some,  and  seems  to  allay  the  distressing 
nausea  often  present. 

Tea- Drinking  in  Sick  Headache. — Some  persons  sustain  themselves 
during  an  attack  of  sick  headache  by  drinking  several  cups  of  tolerably 
strong  tea  in  the  course  of  the  day.  The  tea  seems  to  keep  them  up,  to 
mitigate  the  severity  of  the  headache,  and  to  relieve  the  nausea.  Tea  is 
condemned  in  the  most  unqualified  manner  by  many  members  of  the 
profession;  but  I  cannot  help  thinking  that  the  public  forms  a  more  cor 
rect  estimate  concerning  the  value  of  this  celebrated  infusion.  I  doubt 
whether  it  would  be  possible  to  persuade  old  women  or  old  men,  or  even 
young  men,  as  a  class,  to  give  up  tea.  The  majority  of  people  do  not 
believe  that  tea  does  half  the  harm  attributed  to  it ;  and  with  this  opinion 
I  am  inclined  to  agree.  If,  however,  you  were  ailing,  and  were  to  consult 
many  of  the  most  distinguished  members  of  the  profession  on  the  matter, 
you  would  almost  certainly  be  enjoined  to  give  up  tea,  whether  the  malady 
was  dyspepsia,  constipation,  or  sick  headache ;  and,  indeed,  for  many 
slight  ailments,  the  most  important  curative  measure  would  seem  to  be  to 
abstain  from  tea.  Some  practitioners  express  this  opinion  with  amazing 
confidence  and  absolutism.  Milk  and  water  or  wine  and  water  are  sug- 
gested as  substitutes — substitutes  for  tea !  Your  medical  adviser  fairly 
argues  that  something  or  other  must  be  wrong,  and  infers  that  you  take 
something  that  you  ought  not  to  take  ;  that  this  something  must  be  at 
the  root  of  the  evil ;  and  then  concludes,  but  not,  in  my  opinion,  with 
good  reason,  that  the  particular  peccant  matter  is  nothing  less  than  tea. 
Now,  it  is  almost  hopeless  to  attempt  to  alter  the  views  of  those  whose 
minds  are  "  made  up  "  upon  such  a  matter  as  this;  and,  as  regards  the 
deleterious  effects  of  tea,  not  a  few  medical  minds  will  be  found  in  this 
happy  state.  No  one  is  to  be  allowed  to  say  a  good  word  for  tea.  Tea 
is  held  to  be  the  almost  universal  cause  of  dyspepsia,  and  there  is  an  end 
of  the  matter.  But,  in  spite  of  its  condemnation,  tea  is  at  this  time  more 
largely  drunk  than  ever.  Probably  more  than  two  hundred  million 


I  SO  TREATMENT  IN  THE  INTERVALS. 

pounds  of  tea  per  annum  are  consumed  in  the  United  Kingdom  alone: 
and,  if  its  influence  is  as  bad  as  some  assert  it  to  be,  it  is  wonderful  how 
few  people  discover  its  deleterious  qualities.  Seldom,  I  believe,  does 
tea  do  the  harm  that  has  been  attributed  to  it.  In  many  cases  of  sick 
headache,  four  or  five  cups  of  good  tea,  at  intervals  during  the  day,  will 
unquestionably  mitigate  the  severity  of  a  bad  attack,  and,  perhaps,  enable 
the  sufferer  to  pursue  his  ordinary  avocations  in  a  way  that  he  could  not 
otherwise  carry  out.  Strong  coffee  seems  to  suit  some  persons  who  cannot 
take  tea. 

Vomiting  sometimes  goes  on  for  four  and  twenty  hours,  and  sometimes 
for  a  longer  period.  The  patient  may  be  much  exhausted,  and  the 
stomach  become  weak  and  very  tender.  Three  or  four  days  often  pass 
before  the  patient  regains  his  normal  state  of  health,  and  is  again  able  to 
digest  food. 

2.  TREATMENT  IN  THE  INTERVALS  BETWEEN  THE  ATTACKS. 

Now,  as  to  the  treatment  in  the  intervals  between  the  attacks.  After 
having  tried  many  different  systems  of  diet,  with  the  view  of  preventing 
attacks  of  sick  headache,  as  I  have  already  mentioned,  I  have  come  to 
the  conclusion  that,  upon  the  whole,  the  best  plan  is  to  live  pretty  well, 
and  not  to  be  too  fidgety  as  regards  food.  In  one  or  two  days  after  the 
attack  has  passed  off,  the  stomach  begins  to  digest,  and,  in  most  cases, 
it  will  readily  digest  the  ordinary  things  taken  in  health.  I  do  not  think 
that  a  restrictive  diet,  of  any  kind,  is  of  much  advantage ;  and  if  the 
plan  adopted  lowers  the  general  health,  there  is  no  doubt  that  the  attacks 
of  sick  headache  will  not  only  come  on  more  frequently,  but  they  will 
be  more  severe.  I  should  say  to  those  who  suffer  from  this  troublesome 
ailment,  "Live  fairly  well  while  you  can,  and  when  the  sick  headache 
comes  on,  entirely  abstain  from  food  for  a  time.  As  soon  as  the  attack 
has  passed  off,  live  as  usual,  and  think  as  little  as  possible  of  the  malady." 
A  great  many  persons  are  certainly  too  careful,  as  regards  diet,  in  sick 
headache  as  well  as  in  many  other  slight  ailments.  I  fear,  too,  it  must 
be  confessed  that  many  doctors  encourage  this,  and  give  minute  directions, 
as  to  food,  which  are  as  unpractical  as  they  are  meaningless  and  useless. 
A  parcel  of  very  absolute  rules  is  laid  down  for  patients'  guidance,  many 
of  which  rest  upon  no  principles  whatever,  and  are  but  needless  arbitrary 
enactments.  If  they  were  called  upon  to  give  their  reasons  for  the  rules 
they  have  made,  they  would  find  themselves  in  a  very  serious  difficulty. 
Many  of  the  very  precise  directions  that  have  been  given  to  people  suffer- 
ing from  slight  ailments  are  really  quite  ridiculous.  Even  if  some  patients 
are  a  little  silly,  it  is  certainly  not  our  duty  to  treat  them  as  if  they  were 
utterly  devoid  of  sense.  Give  reasonable  and  necessary  directions  as  to 
diet  by  all  means,  and  see  that  patients  do  not  exceed  in  any  way,  but 
do  not  write  minute  directions  concerning  the  precise  thickness  of  the 
bread  and  the  exact  quantity  of  butter,  and  do  not  give  written  orders 


BETWEEN   THE  ATTACKS.  l8l 

as  to  whether  the  toast  is  to  be  taken  hot  or  cold,  buttered  or  without 
butter.  Such  trumpery  minutiae  will  be  regarded  as  feeble  affectations 
by  all  sensible  patients. 

If  people,  who  are  merely  dyspeptic  or  bilious  or  inclined  to  headache, 
are  allowed  to  be  too  particular  as  to  what  they  may  or  may  not  eat, 
they  get  very  fidgety,  and,  perhaps,  at  last  loathe  almost  all  food.  In 
consequence  "they  lose  in  weight,  simply  because  they  do  not  get  food 
enough  to  sustain  them.  Thus  such  persons  often  get  into  a  low  hypo- 
chondriacal  condition,  and  some  real,  and  perhaps  serious,  illness  may 
come  on. 

Many  who  suffer  from  sick  headache  discover,  if  they  will  only  try  the 
experiment,  that  they  can  eat  pretty  much  as  other  people  do  .in  the 
^intervals  between  the  attacks ;  and,  if  they  can  manage  to  eat  fairly  well, 
they  will  find  that,  instead  of  suffering  from  a  greater  number  of  attacks, 
they  escape  with  fewer.  Most  who  suffer  from  sick  headache  require, 
and  can  take,  but  very  little  stimulant.  Many  are  better  without  any 
stimulants  whatever.  Beer  will,  often  precipitate  an  attack,  and  wine 
generally  disagrees.  A  teaspoonful  of  sherry,  taken  between  meals,  is 
sufficient  to  bring  on  an  attack  in  one  predisposed  to  the  ailment.  There 
are,  however,  exceptions  to  this ;  for  I  know  some  who  find  that  a  little 
sherry  or  beer  helps  them  in  the  intervals  between  the  attacks,  and  does 
not  seem  to  bring  one  on  unless  it  happens  to  be  imminent. 

All  sufferers  from  sick  headache  should  do  all  they  can  to  avoid  worry. 
Peace  of  mind  and  freedom  from  anxiety  are  of  course  to  be  desired  for 
every  one,  but  those  prone  to  the  malady  we  are  considering  should  be 
doubly  careful,  and  should  avoid  undertaking  responsibilities  which 
make  them  anxious.  So  also  they  should  exercise  as  much  self-control 
as  possible,  and  endeavor  not  to  give  way  to  a  feeling  of  restlessness 
and  fussiness,  which  only  increases  the  severity  of  the  attacks  which 
they  have  to  suffer. 

Many  saline  medicines,  which  increase  secretion,  seem  to  be  useful  to 
those  who  suffer  from  sick  headache.  Small  doses  of  Nitrate  of  Potash, 
Potasses  Nitras,  Bicarbonate  of  Potash,  Potassce  Bicarbonas,  the  so-called 
effervescing  Citrate  of  Magnesia,  or  Liquor  Ammonia  Acetatis,  or  Liquor 
Potassa,  may  be  ordered  to  be  taken  in  a  largely  diluted  state  early  in 
the  morning  before  the  breakfast,  and  the  last  thing  at  night.  Or  you 
may  give  half  a  tumbler  of  Vichy  Water,  or  Lithia  Water,  or  German 
Seltzer  Wafer  at  the  same  time  of  the  day,  for  a  few  days  at  a  time,  in 
the  intervals  between  the  attacks  of  sick  headache. 

Some  bitter  preparations  also  seem  to  be  of  use.  You  may  give  Infu- 
sion of  Orange,  Infiisum  Aurantii,  or  Infusion  of  Quassia,  Infusinn  Quas- 
sia;, or  Quinine ;  or,  as  I  have  suggested  before,  you  may  try  the  effect 
of  tea  or  coffee  in  somewhat  larger  quantity  than  they  are  usually  taken. 

A  good  deal  has  been  said  lately  about  Guarana.  It  is  prescribed  in 
powder,  in  doses  of  from  ten  to  thirty  grains  twice  or  three  times  a  day. 
16 


1 82  EFFECTS   OF  CALOMEL. 

Its  active  principle  has  also  been  extracted,  and  may  be  prescribed  in 
doses  of  from  one  to  three  or  four  grains.  I  am  indebted  to  Messrs. 
Savory  and  Moore  for  a  specimen  of  Guaranine.  It  looks  something 
like  quinine,  but  is  more  flocculent.  The  taste,  though  bitter,  is  very 
unlike  the  taste  of  that  substance.  There  is  also  a  Liquid  Extract  of 
Guarana,  Extractum  Guarance  liquidum,  the  dose  of  which  is  from  twenty 
to  thirty  minims.  I  am  sorry  to  say  that,  although  benefit  seems  to  have 
beent  derived  by  some,  many  have  tried  this  remedy  without  gaining  the 
hoped-for  advantage  from  its  use. 

General  treatment  in  the  intervals  of  comparative  good  health  must 
not  be  forgotten.  Tonics  of  various  kinds  are  often  useful.  You  may 
give  Quinine  in  one-  or  two-grain  doses  twice  daily,  about  eleven  and 
four  o'clock,  or  Quinine  Wine,  or  Tincture  of  Quinine.  Various  other 
bitter  tonics  and  the  mineral  acids  maybe  prescribed  in  many  cases  with 
advantage.  The  above  remedies  must,  however,  be  withheld  as  soon  as 
the  headache  begins  and  while  it  lasts. 

If  the  patient  suffers  from  constipated  bowels,  you  must  give  mild 
purgatives.  If  the  various  excreting  glands  do  not  sufficiently  freely 
perform  their  work,  you  must  prescribe  those  remedies  which  act  upon 
the  liver,  kidneys,  or  other  organs  at  fault.  Whether  Calomel  should  be 
given  now  and  then  is  a  point  upon  which  there  is  much  difference  of 
opinion.  Some  patients  undoubtedly  derive  great  benefit  from  small 
doses  of  this  drug.  From  one  to  two  or  three  grains,  taken  at  intervals 
of  three  or  four  days,  is,  as  I  have  before  remarked,  treatment  which 
really  deserves  in  certain  cases  to  be  called  curative.  There  are,  how- 
ever, a  few  persons  who  cannot  take  Calomel.  If  you  give  even  half  a 
grain,  the  salivary  glands- will  begin  to  act  within  three  or  four  hours, 
and  soon  secrete  violently.  The  saliva  flows  from  the  mouth,  the  tongue 
and  cheeks  swell,  the  teeth  become  loose,  and  the  patient  is  in  too  much 
suffering  to  talce  food,  and  too  ill  to  digest  it  properly  if  he  could  take 
it.  You  must  be  aware  of  this  extraordinary  susceptibility  to  the  action 
of  Mercury,  and  do  not  order  it  if  the  patient  or  friends  assure  you  that 
it  has  this  effect.  Sometimes  Calomel  seems  to  weaken  patients  terribly. 
Small  doses  purge  them  too  much,  and  harm,  instead  of  good,  results. 
On  the  other  hand,  I  can  assure  you  that  the  confident  unqualified  con- 
demnation of  mercurials  that  has  lately  been  so  fashionable  rests  on  no 
foundation  of  fact.  It  is  one  of  those  fads  or  fancies  which,  being  acted 
upon,  are  very  interfering  with  our  usefulness  to  the  sick.  It  is,  of  course, 
easy  to  bring  forward  numerous  instances  where  persons  have  been  known 
t'o  take  Mercury  almost  daily  for  thirty  or  forty  years,  not  only  without 
suffering,  but,  from  their  own  account,  with  great  benefit.  Indeed,  some 
will  tell  you  that  they  cannot  get  on  without  an  occasional  small  dose. 
Many  Mercury-takers  have  lived  to  be  very  old.  I  could  give  examples 
of  life  being  prolonged  beyond  eighty-four  years,  although  one  or  two 
grains  of  Blue  Pill  had  been  taken  every  fourth  or  fifth  day  for  forty 


MANAGEMENT  OF  SICK  HEADACHE.  * 

years.  I  have  been  told  by  people  that  they  had  been  distinctly  warned 
by  their  medical  adviser  upon  no  account  to  take  Calomel,  on  the  ground 
that  if  they  did  take  the  drug,  it  would  almost  kill  them,  or  would  at 
least  provoke  some  serious  and  lasting  injury  to  tissues  and  organs,  and 
damage  the  constitution.  Such  assertions  are  merely  arbitrary  utter- 
ances. It  is  a  fact,  as  I  have  told  you  before,  that  Calomel  enters  into 
the  composition  of  many  powders  which  have  a  great  reputation  for  ex- 
erting a  soothing  effect  upon  irritable  children,  and  which  are  given 
even  to  young  infants  for  the  sake  of  improving  the  temper.  It  is 
wrong  for  practitioners  to  lay  down  the  law  against  the  use  of  such  a 
remedy  as  Mercury.  The  public  are  sufficiently  capricious  to  make  it 
difficult  to  advise  them  for  the  best,  and  it  is  very  injudicious  on  the  part 
of  a  skilled  practitioner  to  encourage  fancies  and  prejudices.  Calomel, 
by  helping  the  action  of  the  stomach  and  liver,  restores  digestion,  and 
even  an  infant  soon  regains  its  good  humor.  Adults  experience  a  pleas- 
ant sensation  if  digestion  goes  on  quietly  and  effectually;  while,  on  the 
other  hand,  if  the  digestive  process  is  interfered  with,  the  most  amiable 
persons  will  find  it  difficult  to  keep  themselves  in  that  desirable  state. 
If  they  do  not  feel  out  of  temper,  they  probably  experience  despond- 
ency, and  feel  melancholy  and  out  of  heart. 

So  far,  the  reputed  substitutes  for  mercurials  which  I  have  tried  have 
not  succeeded  -as  I  could  wish ;  but  I  have  not  yet  had  an  opportunity 
of  giving  in  a  sufficient  number  of  cases  of  sick  headache  and  other 
maladies  where  the  liver  is  at  fault,  the  new  remedies  recommended  by 
Professor  Rutherford. 

3.    OF   THE    MANAGEMENT   OF   SICK   HEADACHE   WHEN    THE   PATIENT   CON- 
TINUES  TO   WORK. 

The  following  plan  has  been  found  to  answer,  in  several  instances,  in 
mitigating  the  severity  of  the  attack  while  the  patient  continued  his  usual 
avocation.  The  victim  may  become  conscious  of  the  attack  as  soon  as 
he  wakes  in  the  morning,  and,  instead  of  attempting  to  eat  any  breakfast, 
he  should  .take  only  a  cup  of  rather  strong  tea.  In  the  commencement 
there  is  a  feeling  of  weakness  and  lassitude,  often  accompanied  by  giddi- 
ness ;  but  the  patient  can,  nevertheless,  walk  about,  and  so  far  from 
feeling  exhausted,  as  he  certainly  would  do  if,  under  ordinary  circum- 
stances, he  was  deprived  of  the  first  and,  with  some,  most  important, 
meal  in  the  day,  he  will,  very  probably,  not  feel  the  slightest  demand  for 
food.  In  an  hour  or  two  he  may  take  another  cup  of  tea ;  and  the  dose 
may  be  repeated  at  intervals  through  the  day.  A  little  milk  and  sugar 
may  be  allowed ;  but,  probably,  the  simple  infusion  of  a  good  tea,  taken 
warm,  would  be  best. 

In  this  way  the  patient  may  get  through  his  work,  with  difficulty,  no 
doubt,  and,  perhaps,  he  may  feel  somewhat  miserable;  but  the  time 
passes  more  quickly  than  if  he  were  lying  down  and  contemplating  his 


1 84  DR  O  WSINESS. 

pain.  Towards  evening,  in  many  cases,  the  discomfort  becomes  less,  a 
sensation  of  emptiness,  not  difficult  to  bear,  is  experienced,  and  this  is 
gradually  followed  by  an  actual  desire  for  food.  But  the  most  striking 
change  which  sets  in  about  this  time,  and  which  is  an  invariable  indica- 
tion of  a  favorable  turn  in  the  progress  of  the  malady,  is  the  free  secretion 
of  urine,  after  the  action  of  the  kidneys  has  been  nearly  suspended  for 
four-and-twenty  or  forty-eight  hours,  or  more.  At  first,  a  small  quantity 
of  very  acid  urine,  of  high  specific  gravity,  makes  its  appearance  in  the' 
bladder ;  but  this  is  soon  followed  by  a  very  free  secretion  of  pale  urine, 
of  low  density,  and  great  relief  of  all  the  distressing  symptoms  is  at  once 
experienced.  The  stomach  will  now  bear  a  little  light  food.  The  large 
bowel  begins  to  resume  its  function,  and  next  morning  the  patient  will 
probably  wake  up  feeling  nearly  well.  If,  however,  the  headache  still 
troubles  him  when  he  -rises,  it  usually  passes  quite  away  during  the  day. 
•  It  is  true  that  in  many  cases  the  attack  is  often  more  severe,  and  its 
duration  longer,  than  I  have  indicated ;  but  the  general  plan  of  treatment 
suggested  should  be  the  same — complete  abstinence  from  solid  food,  the 
administration  of  tea,  coffee,  or  even  plain  water,  at  intervals  of  two  or 
three  hours,  until  the  headache  nearly  ceases  and  the  nausea  disappears. 
Some  people  like  warm  water  flavored  with  lemon-juice ;  and  you  may 
add,  with  advantage,  Supertartrate,  or  Nitrate,  or  Citrate  of  Potash,  or 
some  other  salt  known  to  act  as  a  diuretic. 

It  would  appear  that  during  the  attack  of  headache  most  organs  of  the 
body,  and  notably  the  secreting  organs,  strike  work.  It  is  useless  to  try 
to  violently  and  immediately  excite  them  to  action,  for  you  would  do 
harm  by  such  attempts.  You  must  wait  for  a  few  hours ;  and  as  soon  as 
you  see  the  slightest  tendency  of  a  return  to  activity,  I  believe  you  may 
be  of  use  in  saving  time  and  hastening  the  return  to  convalescence.  A 
free  flow  of  urine,  I  am  sure,  is  advantageous,  and  lemon-juice,  nitre, 
with  plenty  of  water,  will  often  effect  this  object.  Purgatives  do  harm 
if  given  too  soon;  and  I  have  not  been  satisfied  as  to  the  advantage 
derived  from  many  other  remedies  that  have  been  warmly  recommended 
during  the  attack.  Neither  warm  baths  nor  cold  baths  seem  to  be  of 
use ;  and  with  the  exception  of  tea  or  water  flavored  with  lemon-juice, 
with,  perhaps,  some  simple  saline  diuretic,  the  less  introduced  into  the 
stomach  during  the  twenty-four  or  thirty  hours  of  suffering  the  better. 
In  conclusion,  let  me  impress  upon  you  the  inference  that  sick  headache 
is  not  an  unmixed  evil.  The  condition  has  its  advantageous  side,  for 
he  who  is  subject  to  the  malady  generally  finds  no  difficulty  in  keeping 
temperate,  and  the  delicacies  of  the  table  are  to  him  scarcely  a  temptation. 
Thus  he  is  less  likely  to  suffer  from  early  failure  and  degeneration  of 
important  organs  than  many  apparently  healthy  persons  who  may  over- 
work them  and  subject  them  to  undue  strain. 

Drowsiness. — Patients  sometimes  come  to  consult  us  in  consequence 
bf  a  persistent  sleepy  state.  They  will  tell  you  that  they  feel  as  if  they 


RESTLESSNESS.  185 

could  sleep  all  day  as  well  as  all  night.  If  they  sit  on  a  chair  for  a  few 
minutes,  they  drop  off  to  sleep ;  if  they  take  up  a  book  or  a  paper,  it  soon 
falls  from  their  hands  in  consequence  of  an  irresistible  drowsiness.  If 
they  go  out  for  a  walk,  they  soon  begin  to  experience  a  strong  inclination 
to  lie  down  and  yield  themselves  up  to  sleep.  Patients  who  suffer  in  this 
way  sometimes  come  for  help  to  their  medical  adviser.  They  may  feel 
pretty  well,  and  in  good  health,  with  the  exception  of  this  irrepressible 
drowsy  feeling,  and  they  ask  you  what  they  can  do  to  get  rid  of  a  ten- 
dency so  very  troublesome  and  inconvenient. 

In  many  cases  this  drowsy  state  seems  to  depend  upon  some  imperfect 
action  of  the  digestive  organs.  Sometimes  it  may  be  traced  to  over- 
feeding. Sometimes  to  taking  too  large  a  meal  in  the  middle. of  the  day. 
Sometimes  beer  or  a  too  liberal  allowance  of  wine  seems  to  be  the  cause 
of  it.  If  you  give  mild  purgatives  and  mineral  acids  before  meals,  and 
saline  medicines  which  act  upon  the  intestinal  canal,  you  will  often  suc- 
ceed in  curing  the  patient.  When  the  liver  is  in  fault,  as  is  not  unfre- 
quently  the  case,  you  will  find  the  advantage  of  giving  a  small  dose  of 
Calomel,  Blue  Pill,  or  Gray  Powder  (from  one  to  two  grains  will  be  suf- 
ficient) every  third  .or  fourth  night  for  three  or  four  courses. 

Cold  bathing  also  is  often  useful.  As  soon  as  the  patient  rises  in  the 
morning  he  may  have  a  cold  shower-bath.  There  is  no  need  of  a  large 
quantity  of  water.  A  shower-bath  of  two  or  three  pints  will  be  sufficient. 
If  the  drowsiness  is  very  troublesome,  two  moderate  shower-baths  a  day 
may  be  tried — one  at  about  eleven,  the  other  at  four  o'clock — cold  or 
tepid,  according  to  the  time  of  year.  In  some  cases,  in  addition  to  the 
cold  bathing,  a  mild  purgative  every  night  for  a  week  will  be  found 
useful. 

Wakefulness  and  Restlessness. — The  very  opposite  condition  to  drow- 
siness afflicts  some  patients.  They  come  to  you  complaining  that  they 
cannot  sit  still  or  rest  quietly  for  a  time.  They  experience  a  strong 
desire  to  be  continually  walking  about.  They  cannot  stay  for  long  in 
one  place,  and  do  not  feel  satisfied  unless  they  get  constant  change  of 
scene.  You  inquire  if  there  is  any  cause  for  this  restlessness,  and,  as  a 
rule,  the  invalid  assures  you  that,  although  everything  is  going  on  in  its 
usual  way,  he  cannot  feel  satisfied,  quiescent,  or  composed.  Sometimes 
vague  frights  harass  the  patient.  When  he  goes  to  bed  at  night,  instead 
of  dropping  off  to  sleep  in  a  natural  way,  he  lies  tossing  about.  The 
pillow  seems  uncomfortable,  and  soon  gets  too  warm  for  the  head.  A 
very  miserable- night  is  passed,  and  the  patient  only  gets  a  little  sleep 
towards  morning,  and  perhaps  wakes  up  feeling  tired,  exhausted,  and 
unrefreshed.  The  mental  disturbance  in  these  cases  depends  upon  some 
temporary  derangement  which  cannot  be  accurately  defined.  If  upon 
inquiry  you  learn  that  the  restless  state  has  existed  for  a  considerable 
time,  you  must  induce  the  patient  to  thoroughly  change  his  mode  of  life. 
If  he  is  in  business,  recommend  him  to  get  away  and  take  a  holiday  for 
16* 


1 86  TREATMENT  OF  WAKEFULNESS. 

a  time.  Send  him  to  some  place  where  he  will  get  complete  change  of 
scene  for  a  month  or  more.  The  diet  must  at  the  same  time  be  carefully 
regulated,  and  in  all  probability  the  patient  will  return  home  well,  and 
able  to  go  on  with  his  daily  round  of  duty  just  as  steadily  as  he  did 
before  the  illness  commenced. 

Persons  who  suffer  from  wakefulness  are  often  ordered  to  take  Chloral, 
and  after  finding  out  the  efficacy  of  the  remedy,  some  very  imprudently 
continue  its  use  without  consulting  their  medical  adviser.  In  a  short 
time  they  discover  that  they  cannot  sleep  at  all  without  the  drug,  and 
at  last  they  become  complete  slaves  to  its  use.  It  has  happened  that 
from  want  of  due  care  an  overdose  has  been  taken,  and  death  has  resulted. 
It  is  important  to  caution  all  persons  for  whom  you  prescribe  Chloral, 
never  to  take  this  drug  unless  it  is  specially  ordered  for  them.  More 
dangerous  even  than  Chloral-taking  is  the  hypodermic  injection  of  nar- 
cotics, and  it  seems  to  me  that  this  method  ought  never  to  be  employed 
in  cases  of  occasional  wakefulness,  and  I  think  that  in  all  cases  the  rule 
should  be  observed  of  never  leaving  the  syringe  and  morphia  solution  in 
the  patient's  custody,  nor  should  any  one  be  allowed  to  perform  the  oper- 
ation for  you.  In  those  cases  only  in  which,  owing  to  chronic  incurable 
disease,  accompanied  by  constant  severe  pain,  the  unfortunate  patient 
can  get  no  sleep  or  peace  without  the  aid  of  morphia,  and  only  very 
exceptionally,  should  this  rule  be  relaxed,  and  non-professional  persons 
permitted  to  inject  the  narcotic.  , 

Patients  oftentimes  complain  of  feeling  tired  and  exhausted  as  well  as 
restless,  and  sometimes  they  will  tell  you  that  they  cannot  walk  half  a 
mile  in  consequence  of  being  muscularly  weak.  You  must  carefully 
inquire  into  the  state  of  the  various  functions  of  the  body,  and  suggest 
what  you  can  to  rectify  the  action  of  any  which  are  improperly  dis- 
charged. (See  p.  113.)  Generally,  you  will  do  well  to  send  such  patients 
for  a  moderate  tour  in  a  pleasant  part  of  the  country,  where  they  can  see 
a  good  deal  without  walking  very  far.  You  must  particularly  caution 
them  against  over-fatigue.  Many  persons  suffering  from  this  or  other 
conditions  requiring  change,  are  advised  to  take  a  walking  tour  in  Swit- 
zerland or  the  Tyrol.  So  they  go  with  all  despatch,  and  having  arrived 
at  their  destination,  begin  their  pedestrian  cure.  Not  having  been  accus- 
tomed to  much  exertion  for  many  years,  they  set  to  work  and,  perhaps, 
walk  twenty  miles  or  more  a  day.  Instead  of  feeling  better,  and  gain- 
ing strength,  they  soon  feel  terribly  tired  and  exhausted,  and  return  home 
in  every  respect  worse  than  when  they  set  out.  Such  an  expedition,  under 
the  circumstances,  is  a  mistake.  You  must  strongly  impress  upon  such 
patients  that  they  are  not  to  walk  more  than  a  mile  at  first,  and  if  they 
are  tired,  they  are  to  sit  down,  or,  better,  lie  down  on  a  sofa,  and  read  a 
novel,  or  otherwise  amuse  themselves.  They  should,  as  we  say,  moon 
about,  or  potter  about  in  the  open  air  several  hours  daily,  without  taking 
any  active  exercise.  In  this  way,  most  sufferers  will  soon  begin  to  im- 


NER  VO  US  NESS.  1 8/ 

prove,  and  when  this  is  the  case,  they  may  by  degrees  extend  their  daily 
walk  until  they  are  restored  to  health. 

Nervousness. — There  is  another  condition,  which  is  usually  called 
"nervousness."  In  this  state  there  can  be  no  doubt  that  the  mind  is, 
in  some  degree,  temporarily  affected.  There  may  be  undue  emotional 
excitement.  The  least  thing  may  arouse  fear  or  dread  ;  but  instead  of 
the  nervous,  excited  state  impelling  the  patient  to  be  more  active  in  his 
work,  he  finds  it  almost  impossible  for  him  to  discharge  his  ordinary 
.duties.  A  large  proportion  of  the  population  seems  never  to  have  experi- 
enced anything  approaching  to  nervousness,  but  some  people  suffer  from 
it  in  a  terrible  degree.  I  have  been  told  by  patients  that  for  some  time 
they  had  been  -conscious  of  an  indescribable  anxiety,  for  which  they 
could  not  account,  and  from  which,  by  no  reasoning  with  themselves, 
could  they  get  relief.  They  know  and  acknowledge  that  there  is  no 
reason  for  anxiety ;  but,  nevertheless,  a  sort  of  ill-defined  dread  seems 
to  hang  over  them.  They  fear  that  something  or  other  is  about  to  hap- 
pen ;  and  this  most  painful  state  of  mental  disturbance  sometimes  lasts 
for  a  considerable  time,  causing  the  patient  great  suffering.  With  this 
state  is  frequently  associated  considerable  depression  of  spirits.  The 
subject  of  it  feels  as  if  everything  was  going  wrong  with  him.  He  may 
be  getting  on  just  as  well,  and  making  quite  as  much,  or  even  more, 
money  than  usual,  but  nevertheless  feels  discontented  and  depressed,  as 
if  something  terrible  had  happened.  People  who  suffer  in  this  way  some- 
times tell  you  that  they  are  certainly  going  to  the  workhouse,  and  all  this 
sort  of  thing,  although  they  know  themselves  to  be  prospering.  If  a 
patient  in  this  state  of  health  should  happen  to  lose  a  few  shillings,  he 
will  feel  quite  convinced  that  everything  is  going  to  the  dogs,  and  nothing 
will  persuade  him  to  give  up  the  despairing  views  of  life  which  have 
somehow  arisen  in  his  mind. 

People  w,ho  suffer  from  extreme  nervousness,  combined  with  a  restless, 
unsettled  state  of  mind,  occasionally  do  very  curious  things.  A  man  may 
wake  up  suddenly  in  the  middle  of  the  night  and  with  the  conviction 
he  smells  fire.  He  gets  out  of  bed,  strikes  a  light,  goes  over  the  house, 
finds  nothing  the  matter,  and  goes  to  bed  again.  In  another  hour  or 
two,  perhaps,  he  wakes  up  a  second  time,  and  goes  through  the  same 
proceedings  as  before.  Many  people  whose  nervous  system  is  a  little 
overwrought,  wake  up  at  night,  and  jump  out  of  bed,  and,  perhaps,  light 
a  candle  before  they  are  quite  aware  of  what  they  are  doing.  A  further 
development  of  the  same  tendency  may  lead  to  sleep-walking,  of  which 
condition  again  there  are  many  different  degrees.  Children  of  highly 
nervous  temperament  are  likely  to  suffer  from  attacks  of  chorea.  These 
and  many  more  severe  disturbances  of  the  nervous  system  seem  to  depend 
upon  a  highly  sensitive  or  excitable  state  of  certain  parts  of  the  central 
nerve  organs,  rather  than  upon  any  abnormal  or  morbid  change.  They 
are,  however,  often  associated  with  a  special  type- of  organism;  and 


1 8  8  NER  VO  US  NESS. 

frequently  it  will  be  found  that  cardiac  disease,  affecting  either  the  mitral 
or  aortic  orifice,  or  both,  also  exists,  or  is  developed  before  the  period 
of  adolescence. 

But  sometimes  an  unusually  restless  and  excitable  state  of  the  nervous 
system  temporarily  troubles  people,  and  may  come  on  at  almost  any 
period  of  life.  The  patient  in  such  a  state  should  be  advised  to  visit 
friends,  or  take  a  holiday  abroad.  You  should  urge  him  to  leave  for  a 
time  his  ordinary  avocations,  and  very  likely  in  a  few  weeks  he  will 
recover  from  his  nervousness.  Upon  careful  inquiry,  you  will  find  that, 
many  who  suffer  in  this  way  have  been  long  in  the  habit  of  taking  too 
little  sleep.  There  is  hardly  anything  in  which  individuals  more  widely 
differ  from  one  another  than  in  the  time  required  for  sleep.  Some  can 
do  with  six  or  seven  hours,  but  it  is  quite  certain  that  many  require  nine 
hours.  Nervous  people,  as  a  rule,  are  benefited  by  a  long  night's  rest 
now  and  then,  and  require  an  average  of  eight  or  nine  hours. 

Of  late  years,  very  much  has  been  written  on  the  subject  of  nervousness, 
and  attempts  have  been  made  to  show  that  we  are  much  more  "  nervous" 
than  our  fathers  were.  It  seems  to  me  that  the  evidence  adduced  in  favor 
of  the  statement  is,  to  say  the  least,  very  far-fetched.  The  so-called 
brain-workers  are  supposed  to  be  great  sufferers.  It  is  said  that  people 
are  more  sensitive  to  heat  and  cold,  and  require  to  live  in  rooms  more 
highly  heated  than  was  the  case  even  a  few  years  ago.  It  must,  however, 
be  borne  in  mind  that  a  far  greater  number  of  the  existing  population 
are  able  to  have  the  advantage  of  warm  rooms  in  cold  weather  than  for- 
merly, and,  in  consequence,  the  majority  enjoy  better  health,  and  live 
to  be  older.  That  large  incomes  engender  a  good  deal  of  fussiness,  and 
little  aches  and  pains  which  are  made  too  much  of,  is,  I  dare  say,  true ; 
and  if  this  is  "nervousness,"  an  increase  no  doubt  exists,  and  such 
"nervousness"  will  increase  as  prosperity  increases.  But  I  cannot  help 
thinking  that  if  our  fathers  had  been  as  prosperous  as  we  are.  as  large  a 
percentage  would  have  suffered  from  "  nervousness."  However  this  may 
be,  it  is  quite  certain  that  if  our  modern  habits  and  systems  are  productive 
of  increased  nervousness,  they  are  at  the  same  time  conducive  to  health 
and  longevity.  There  is  no  doubt  whatever  that  the  general  health  of 
the  population  has  improved,  and  is  improving,  that  the  average  duration 
of  life  is  on  the  increase,  and  if  the  sum  of  human  happiness  is  not  much 
greater  every  succeeding  decade,  it  ought  to  be  so ;  and  the  fault  lies  in 
the  circumstances  that  individual  evil  inclinations  are  capable  of  counter- 
acting the  natural  influence  of  highly  advantageous  external  circumstances. 
Upon  the  whole,  I  doubt  very  much  whether  there  is  anything  to  justify 
many  of  the  statements  made  about  the  increase  of  nervous  disorders. 
Whenever  money  is  made  rapidly,  luxury  and  folly  will  increase ;  but 
the  silly  rich,  after  all,  constitute  but  a  very  small  part  of  the  popula- 
tion— so  small  a  part  that,  in  the  life  of  a  country  like  England,  their 
existence  is  hardly  noted,  except  by  themselves  and  the  few  whose  inter- 


NEURALGIA  AND  'ITS   TREATMENT.  189 

est  leads  them  to  minister  to  their  requirements  and  to  pander  to  their 
caprices. 

Dr.  G.  M.  Beard,  of  New  York,  has  lately  called  attention  to  the 
increase  of  nervousness  in  the  United  States,  but  I  think  his  remarks 
can  only  apply  to  a  very  small  fraction  of  the  population  of  some  of  the 
large  cities.  This  author  seems  to  think  very  much  of  pork  as  a  food, 
and  to  have  formed  a  low  estimate  of  those  whose  stomachs  are  not 
strong  enough  to  digest  it.  The  dethronement  of  pork,  says  Dr.  Beard, 
is  having  a  disastrous  effect  upon  the  American  people — "  Pork,  like  the 
Indian,  flies  before  civilization."  Really  it  seems  very  hard  that  people 
who  cannot  digest  pork  should  be  put  down  as  unduly  nervous,  over- 
sensitive, and  the  like,  and  be  accused  of  undergoing  deterioration  and 
decay.  I  have  no  doubt  that  the  American  nation  will  survive  and 
increase  in  numbers  and  in  vigor,  "the  dethronement  of  pork"  not- 
withstanding. 

As  regards  the  effects  of  overworking  the  brain  in  the  case  of  the 
young,  while  it  may  be  admitted  that,  now  and  then,  instances  of  men- 
tal strain  are  met  with,  such  cases  are  exceedingly  rare,  even  in  these 
days,  as  compared  with  the  number  of  persons,  young  and  old,  who  are 
suffering  from  the  very  opposite  condition — from  too  little  mental  exer- 
tion. I  should  say  that,  as  a  fact,  far  more  disease  is  caused  by  too  little 
brain  work  than  too  much. 

Neuralgia. — I  will  now  offer  a  few  remarks  concerning  a  very  impor- 
tant condition  which  is  well  worthy  of  attentive  study,  but  of  which  I 
can  now  treat  only  very  briefly  and  imperfectly.  Every  one  of  you  must 
have  heard  something  about  Neuralgia  and  Neuralgic  pains-,  though  no 
one  has  yet  been  able  to  give  an  adequate  explanation  of  their  causa- 
tion in  many  cases.  Sometimes  these  pains  are  no  doubt  due  to  a  tem- 
porary change  induced  in  the  nerve  itself,  which  may  possibly  be  beyond 
the  means  of  investigation.  Perhaps  the  capillaries  distributed  to  the 
nerve-fibres  constituting  the  trunk  of  a  large  nerve  may  be  unusually 
distended  with  blood.  Possibly  the  circular  muscular  fibres  of  the  little 
arteries  ramifying  amongst  the  bundles  of  nerve-fibres  may  be  tempo- 
rarily relaxed  through  nerve  influence;  and  thus  the  capillaries  distrib- 
uted to  the  particular  nerve  or  particular  part  of  the  nerve  may  become 
much  dilated,  and  thus  pressing  upon  the  adjacent  nerve-tubules,  very 
severe  pain  may  be  occasioned. 

That  the  trunk  of  the  nerve  is  the  seat  of  attack  in  certain  ordinary 
forms  of  neuralgia  is  certain,  and  pain  like  that  of  neuralgia  may  often 
be  produced  by  pressing  or  stretching  or  squeezing  a  nerve-fibre.  If  a 
sensitive  nerve-fibre  be  pressed  upon  by  a  tumor  or  growth  of  any  kind, 
or  be  stretched  over  a  tumor,  great  pain  generally  results,  and  it  may 
continue  perhaps  for  months  if  the  circumstances  causing  the  alteration 
in  the  nerve  persist.  In  certain  cases,  on  the  other  hand,  the  precise 
seat  of  the  affection  is  undoubtedly  in  the  peripheral  distribution  of  the 


TREATMENT  OF  NEURALGIA. 

nerve  where  it  breaks  up  into  expansions,  plexuses,  or  networks  of  ex- 
tremely delicate  fibres. 

Neuralgic  pains,  then,  are  generally  associated  with  branches  known 
to  consist  principally  of  sensitive  nerve-fibres.  Perhaps  the  fifth  nerve 
is  the  greatest  offender  in  these  cases.  You  may  have  neuralgic  pain 
closely  resembling  that  of  toothache,  and  affecting  the  very  same  nerve- 
fibres,  the  tooth  itself  being  free  from  disease.  The  pain  may  be  so 
acute  as  to  lead  both  the  patient  and  his  adviser  to  conclude  that  some 
morbid  change  is  going  on  in  the  pulp  of  the  tooth.  The  dentist  is 
consulted,  and,  unless  he  is  thoroughly  up  to  his  work,  the  tooth  may  be 
injudiciously  extracted,  and  upon  examination  found  to  be  in  perfect 
health.  The  patient,  however,  goes  away  with  the  conviction  that,  al- 
though he  is  minus  a  sound  tooth,  he  has  at  any  rate  experienced  the 
last  twinge  of  pain.  But,  alas  !  before  many  hours  have  passed  the  suf- 
fering returns  as  bad  as  ever.  Torture  as  severe  in  all  respects  as  that 
from  which  he  had  previously  suffered  is  again  experienced,  though  per- 
haps to  the  sufferer  the  pain  may  seem  to  be  situated  in  an  adjacent 
tooth.  The  patient  might  have  one  tooth  extracted  after  another  with- 
out the  neuralgic  pain  being  cured.  Extraction  is  not  the  proper  expe- 
dient in  these  cases. 

In  some  instances  it  is  probable  that  the  attack  depends  upon  some 
change  taking  place  in  the  circulation,  and  that  in  consequence  partly 
of  the  pressure  exerted  by  the  distended  capillary  vessels,  and  partly  in 
consequence  of  changes  produced  in  consequence  of  exudation  amongst 
the  ultimate  ramifications  of  the  nerve-fibres,  or  around  their  bioplasm, 
pain  results,  and  may  persist  for  some  time  until  the  conditions  become 
slowly  altered.  In  a  few  very  intractable  forms  of  toothache,  or  rather 
of  neuralgic  pain  apparently  originating  in  the  tooth-pulp,  it  is  probable 
that  the  nerve-centre  is  the  seat  of  disturbance  due  to  vascular  conges- 
tion, brought  about  by  reflex  action. 

In  cases  in  which  the  pain  depends  merely  upon  some  temporary  dis- 
turbance in  the  branch  of  the  fifth  nerve  which  supplies  the  tooth,  or  in 
the  tooth  papilla  itself,  the  probability  is  that  it  will  yield  to  very  simple 
treatment. 

Treatment  of  Neuralgia. — Sometimes  a  good  sharp  purgative  will  cure 
the  patient  at  once,  but  more  frequently  it  is  necessary  to  follow  up  the 
purgative  with  tonics,  and  especially  preparations  of  bark,  or  Quinine 
itself,  a  mild  purgative  being  also  given  every  few  days.  In  this  way  you 
very  often  cure  obstinate  neuralgic  pains.  You  must,  however,  bear  in 
mind  that  it  sometimes  happens  that  if  Quinine  is  given  by  itself  it  may 
under  some  conditions  of  the  system  increase  the  pain,  even  for  some 
time;  while  if  you  give  a  purgative  in  the. first  instance,  or  combine 
purgative  medicine,  such  as  Sulphate  of  Soda  or  Sulphate  of  Magnesia, 
with  it,  the  Quinine  will  often  act  perfectly  well  and  cure  the  patient. 
When  the  pain  is  intense,  and  is  decidedly  a  neuralgic  pain,  coming  on 


HYPODERMIC  INJECTION.  1 9! 

at  about  the  same  time  of  the  day,  and  lasting  about  the  same  length  of 
time,  you  must  order  a  considerable  dose  of  Quinine  at  once — five  or 
ten  grains, — and  then  from  three  to  five  grains  twice  or  three  times  a 
day.  Some  people  can  take  as  much  as  ten  grains  of  Quinine  twice  or 
three  times  a  day  for  several  days  with  great  relief  to  various  nerve  ail- 
ments. Quinine  may  be  given  in  the  form  of  pills,  or  you  may  place 
the  bitter  powder  on  the  tongue,  or  it  may  be  diffused  through  water,  or 
dissolved  in  water  containing  a  few  drops  of  free  Hydrochloric,  Sulphuric, 
Nitric,  or  Phosphoric  Acid.  The  usual  way  of  giving  Quinine  is  the  last. 
We  order  a  six-ounce  mixture  as  follows  :  Aromatic  Sulphuric  Acid,  three 
drachms;  Quinine,  thirty-six  grains;  Syrup  of  Lemon,  half  an  ounce  or 
more,  and  water  to  six  ounces.  The  dose  will  be  half  an  ounce,  cr  one 
tablespoonful,  with  an  equal  quantity  of  water,  three  times  a  day,  between 
meals,  for  a  fortnight. 

The  old  Muriate  of  Ammonia,  Chloride  of  Ammonium,  Ammonii  Chlo- 
ridum,  is  a  very  valuable  remedy  in  certain  cases  of  neuralgia  which  are 
not  relieved  by  Quinine.  Some  consider  it  as  a  specific,  and  say  that  it 
seldom  fails.  The  remedy  should  be  given  in  good  doses,  and  it  is  often 
useless  to  order  less  than  twenty  grains  or  half  a  drachm.  It  is  not 
pleasant  to  take,  as  it  has  a  peculiar  salt  taste  which  is  di-sagreeable  to 
most  palates.  However,  those  who  have  suffered  much  from  neuralgia 
are  usually  ready  to  try  anything  that  affords  them  prospect  of  relief. 

Salicine  is  sometimes  of  use,  and  may  be  given  in  doses  of  from  five 
to  eight  grains  every  three  or  four  hours  for  one  or  two  days.  Salicylale 
of  Soda  has  been  largely  prescribed  in  the  treatment  of  severe  forms  of 
rheumatism,  and  has  been  given  for  neuralgia.  It  is  not  much  used  in 
slight  forms  of  either  disease,  but  occasionally  it  does  good.  In  many 
cases  of  acute  rheumatism  it  acts  admirably  in  lowering  the  quick  pulse 
and  high  temperature.  It  must  be  given  with  care,  and  the  patient  taking 
it  must  be  well  looked  after,  as  sometimes  it  lowers  the  pulse  and  de- 
presses the  heart's  action  to  a  greater  degree  than  is  desirable. 

Iron.  Arsenic. — Many  preparations  of  iron  may  be  ordered  in  cases 
of  neuralgia,  particularly  if  there  is  reason  to  think  that  the  state  of  the 
blood  is  at  fault.  Arsenic  in  small  doses,  and  given  with  due  care,  may 
be  prescribed  if  the  pain  is  very  severe.  It  is  well  not  to  continue 
arsenic  for  more  than  a  month  at  a  time.  You  may  order  from  three  to 
five  minims  of  Fowler's  solution  of  arsenic,  Liquor  Arsenicalis,  with  a 
little  syrup  of  ginger  and  an  ounce  of  water,  three  times  daily,  soon 
after  food  has  been  taken. 

Opium. — There  are  several  forms  in  which  opium  may  be  given.  A 
small  dose  of  Dover's  powder,  Pulvis  Ipecacuanha  Compositus  (from  two 
to  five  grains),  at  bedtime,  followed  in  the  morning  by  a  mild  saline 
purgative,  if  persisted  in  for  a  few  days  or  a  week,  will  relieve  and 
sometimes  cure  certain  forms  of  neuralgic  pain. 

Hypodermic  Injection. — You  may,  too,  inject  a  solution  of  Morphia 


192  CHL  ORAL-HYDRA  TE. 

under  the  skin  if  the  pains  are  very  severe.  The  sixth  of  a  grain,  or  less, 
of  this  drug  is  sufficient  for  subcutaneous  injection.  The  operation  is 
performed  with  the  aid  of  a  little  injecting  syringe  made  for  the  purpose, 
one  of  many  forms  of  which  I  show  you.  In  this  way,  for  the  time  being, 
you  may  relieve  the  most  exquisite  nerve  pain ;  but  too  often  it  happens 
that,  as  soon  as  the  effects  of  the  Morphia  have  worn  off,  the  pain  returns. 
You  must  know  that  people  are  nowadays  too  apt  to  get  into  the  way  of 
prescribing  sedatives  for  themselves  after  they  have  found  relief,  and  thus 
they  may  do  themselves  great  harm.  You  must,  therefore,  always  exer- 
cise caution  in  prescribing  and  recommending  this  class  of  remedies, 
and  be  careful  to  tell  patients  they  ought  never  to  prescribe  them  for 
themselves.  More  particularly  as  regards  hypodermic  injection  it  is  my 
duty  to  impress  upon  you  the  importance  of  not  allowing  the  patient, 
under  any  circumstances,  to  get  into  the  way  of  operating  upon  himself. 
There  is  really  great  danger  in  this,  for  the  process  is  very  simple  and 
easily  performed ;  and  as  the  relief  is  great,  patients  are  very  apt  to 
assist  themselves  without  waiting  for  the  doctor.  Of  those  who  take 
this  injudicious  course,  not  a  few  get  into  the  habit  of  narcotizing  them- 
selves on  the  slightest  excuse.  Whenever  they  suffer  slight  pain  they  at 
once  resort  to  hypodermic  injection.  As  soon  as  the  effects  begin  to- 
wear  off,  the  pain  recurs,  and  the  dose  is  repeated.  A  vicious  habit  is 
soon  acquired,  and  it  is  difficult  indeed  to  prevent  many  of  those  foolish 
persons  from  going  to  extremes  and  making  themselves  slaves  of  the  rem- 
edy. Very  painful  cases  of  the  kind  come  under  our  notice  from  time 
to  time,  and  every  now  and  then  death  results  from  an  overdose.  Pa- 
tients who  have  contracted  this  habit  of  self-injection  not  uncommonly 
lose  all  control  over  themselves,  and  introduce  narcotics  hypodermically, 
just  as  other  weak-minded  individuals  become  a  prey  to  drink  or  indulge 
in  other  vices.  We  shall  before  long  have  societies  for  the  entire  sup- 
pression of  hypodermic  injection,  if  this  treatment  becomes  much  more 
fashionable  than  it  is. 

Dr.  Sansoni1  s  Disks. — Of  late  years. some  excellent  little  disks  of  gel- 
atine have  been  prepared,  each  of  which  contains  a  given  quantity  of 
the  drug  we  may  desire  to  inject.  All  that  is  necessary  is  to  dissolve  the 
gelatine  disk  in  a  few  drops  of  warm  water  at  the  time  when  it  is  required. 
The  solution  may  then  be  taken  up  by  the  syringe  and  injected  into  the 
subcutaneous  areolar  tissue  of  the  patient.  I  believe  my  friend,  Dr.  San- 
som,  was  the  first  to  suggest  the  employment  of  these  disks,  which  are 
also  used  when  it  is  required  to  apply  atropine  and  other  remedies  to  the 
conjunctiva. 

Chloral-Hydrate  and  Croton  Chloral-Hydrate. — Chloral  is  of  great  use 
in  procuring  sleep  in  many  cases  of  severe  neuralgia,  especially  when  the 
patient  has  been  kept  awake  night  after  night ;  but  you  must  give  it  with 
the  greatest  caution,  and  only  order  one,  or  at  most  two,  doses  on  the 
prescription.  Take  care  also  to  write  full  directions  how  and  when  the 


RHEUMATIC  PAINS.  193 

draught  is  to  be  taken.  The  dose  of  Chloral  is  from  ten  to  twenty  grains, 
with  a  little  syrup,  and  Peppermint  or  other  water.  The  most  convenient 
form  is  the  syrup  of  Chloral-Hydrate,  one  drachm  of  which  contains 
ten  grains  of  the  drug.  Peppermint  or  Ginger  covers  the  taste  of  the 
Chloral  better  than  anything  else.  In  cases  of  old  catarrh  and  emphysema 
it  should  not  be  given.  I  have  seen  it  do  harm  in  several  instances  in 
which  the  heart  was  weak  and  the  right  ventricle  dilated.  Croton-  Chloral 
or  Butyl  Chloral-Hydrate,  which  was  much  used  a  few  years  ago,  when 
it  was  first  discovered,  has  not  been  heard  of  so  much  lately.  It  is 
prescribed  in  doses  of  one  or  two  grains,  to  be  taken  every  two  or  three 
hours.  In  the  "  Lancet,"  for  January  31,  1874,  Dr.  Burney  Yeo  reported 
some  cases  in  which  the  remedy  rjad  been  of  great  service  in  relieving 
very  severe  neuralgic  pain  ;  and  in  the  same  journal,  for  December  2, 
1876,  you  will  find  some  cases  recorded  by  Dr.  Skerritt,  of  Bristol,  in 
which  the  remedy  relieved  bilious  headache,  facial  neuralgia,  and  giddi 
ness.  Five  grains  were  given  twice  a  day. 

Rheumatic  Pains. — I  must  now  say  a  few  words  about  another  kind  of 
pain  which  is  very  common.  It  is,  perhaps,  not  so  severe  as  bad  forms 
of  neuralgic  pain,  but  it  nevertheless  occasions  much  suffering,  and  in 
some  cases  is  so  severe  and  so  constant  as  to  prevent  the  patient  from 
following  his  avocations.  I  allude  to  the  so-called  Rheumatic  Pains, 
which  affect  various  tissues  and  occur  in  many  different  parts  of  the 
body.  The  character  of  the  pain  differs  somewhat  in  different  cases, 
sometimes  occurring  as  sharp,  evanescent  twinges,  which  either  flit  about, 
as  it  were,  from  place  to  place,  or  seem  to  be  obstinately  fixed  in  certain 
joints,  the  severity  of.  the  suffering  altering  only  in  degree.  A  good 
many  old  men  and  old  women,  living  in  damp,  cold,  country  places,  will  . 
tell  you  they  have  been  martyrs  to  rheumatism  for  more  than  half  their 
lives. 

When  the  blood  is  in  a  state  favorable  to  the  development  of  those 
changes  which  result  in  rheumatic  pains,  you  may  be  exposed  to  cold, 
damp  air  for  a  short  time,  towards  sundown,  conscious  of  a  slight  chilly 
feeling,  and  in  two  or  three  hours  you  feel  very  decided  aching  of  the 
muscles  of  the  forearm,  or  upper  arm,  or  of  the  leg,  back,  or  other  part 
of  the  body.  Perhaps  some  of  the  tendinous  structures  about  the  wrist 
or  ankles  are  the  seat  of  fixed,  continuous  pain,  which  becomes  worse  on 
exertion,  and  makes  it  a  matter  of  great  difficulty  to  lift  anything,  or  to 
perform  the  ordinary  movements.  Very  commonly  the  muscles  at  the 
back  of  the  neck,  from  their  insertion  in  the  occipital  bone  downwards, 
are  so  painful  that  you  cannot  turn  or  bend  the  head.  Partly  from  the 
pain  and  discomfort  experienced,  partly  from  the  effect  of  the  altered 
blood  on  sensitive  nerves  of  the  body  generally,  you  feel  quite  ill  and 
must  lie  down.  Now  you  soon  find  out  that  external  warmth  gives  great 
relief.  Sit  before  a  good  fire,  wrap  yourself  up  in  a  railway  rug,  take  a 
warm  bath,  or  hot-air  bath,  or  a  Turkish  bath,  and  the  pains  will  soon 
17  N 


194  MUSCULAR   RHEUMATISM. 

disappear.  If  you  go  to  bed  and  freely  perspire,  you  will  feel  better 
within  an  hour.  But,  perhaps,  after  a  few  hours  more  you  have  evidence 
that  the  pain  has  not  gone,  showing  that  the  changes  which  caused  the 
pain  in  the  first  instance  have  been  followed  by  phenomena  which  deter- 
mine a  more  lasting  departure  from  the  normal  state. 

Rheumatic  pains  are  often  preceded  by,  or  are  associated  with,  flatu- 
lence, heart-burn,  and  other  symptoms,  indicative  of  deranged  digestion. 
Some  suppose  that  the  peccant  matter,  which  causes  the  pain,  is  actually 
secreted  by  the  stomach,  while. others  consider  that  it  results  from  the 
occurrence  of  unusual  chemical  changes  occurring  in  the  recently  absorbed 
constituents  of  the  food.  In  favor  of  this  latter  view  may  be  adduced 
the  fact  that  the  subjects  of  rheumatisrn  are  almost  invariably  made  worse 
by  beer,  while  rheumatics  who  can  be  persuaded  to  give  up  this  popular 
beverage,  almost  invariably  improve.  The  rheumatism,  however,  returns 
whenever  the  beer  is  resumed. 

Rheumatic  pains  differ  from  neuralgic  pains,  inasmuch  as  they  com- 
monly arise  in  muscles  and  fibrous  tissues,  while  neuralgic  pain  is  generally 
seated  in  a  nerve-trunk  or  its  ramifications.  The  dental  nerve  and  its 
branches,  or  the  superior  maxillary,  or  frontal,  or  certain  cutaneous 
branches  in  various  parts  of  the  body,  are  more  frequently  affected  than 
other  nerves.  Rheumatic  pains,  on  the  other  hand,  seem  to  be  situated 
deeper,  more  in  the  substance  of  tissues,  and  to  emanate  from  the  ultimate 
ramifications  of  the  nerves,  distributed  to  tendons  or  fasciae,  or  to  the 
muscles  themselves. 

Lumbago  is  a  form,  and  a  very  unpleasant  one,  of  muscular  or  fibro- 
muscular  rheumatism.  Sometimes  it  is  very  obstinate  and  very  difficult 
to  cure.  The  patient  is  obliged  to  rest  in  bed  ;  and  it  may  be  a  fortnight 
or  more  before  he  is  able  to  bend  his  back  without  great  suffering. 

Rheumatic  pain  seems  in  many  cases  to  arise  near  the  insertion  of  a 
muscle.  The  .point  of  attachment  of  the  deltoid  to  the  humerus  is  a 
frequent  spot  for  the  development  of  rheumatic  pain,  which  may  be  so 
severe  as  to  interfere  with  the  raising  of  the  arm,  and  to  render  the  put- 
ting on  of  a  coat  without  assistance  a  most  difficult  proceeding.  Some- 
times the  pain  persists  in  this  situation  for  several  weeks. 

The  intercostal  muscles  are  not  unfrequently  the  seat  of  very  severe 
rheumatic  pain  which  is  sometimes  mistaken  for  pleurisy.  The  muscles 
of  the  side  and  of  the  hip  are  also  frequently  affected.  Rheumatic  pain' 
in  some  of  the  fibres  of  the  diaphragm  and  of  the  abdominal  muscles 
lias  unfortunately  led  the  practitioner  to  express  the  opinion  that  a  patient 
was  suffering,  from  peritonitis,  and  some  days  perhaps  will  have  elapsed 
before  this  terrible  and  erroneous  diagnosis  has  been  controverted. 

The  nerve-fibres  distributed  to  the  muscular  fibre  cells  (organic  mus- 
cle) may  be  the  seat  of  organic  pain  as  well  as  those  distributed  to  vol- 
untary muscle.  It  is  to  be  remarked  with  reference  to  the  latter,  that 
those  parts  of  the  muscle  situated  nearest  to  the  tendon  are  most  fre- 


NATURE    OF  RHEUMATIC  PAIN.  195 

quently  the  seat  of  the  pain.  Here,  of  course,  the  circulation  through 
the  vessel  is  slowest,  and  there  would  be  the  greater  chance  of  any  exu- 
dation poured  out  from  the  blt>od  producing  a  deleterious  influence  upon 
the  finer  branches  of  any  nerve-fibres  with  which  they  may  come  into 
contact. 

In  various  forms  of  rheumatism,  then,  we  infer  that  certain  of  the 
fibrous  tissues  are  the  seat  of  pathological  change.  Exudation  is  proba- 
bly poured  out  from  the  blood  as  the  circulating  fluid  slowly  traverses  the 
sparsely  scattered  capillaries  of  the  tissues;  The  nerve-fibres  close  to  the 
capillaries  (see  p.  230)  suffer.  The  exudation  coagulates,  and  part  of  it 
is  at  length  converted  into  fibrous  tissue,  so  that  the  affected  textures 
become  thickened,  and  the  movements  of  the  joints  and  of  the  tendons 
and  muscles  in  their  neighborhood  seriously  impaired.  In  many  old 
cases  of  chronic  rheumatism  the  patient  becomes  seriously  crippled, 
and  the  movements  of  some  joints  are  greatly  impeded  if  not  altogether 
stopped.  It  would  almost  seem  as  if  in  bad  cases  of  rheumatism  the 
fibrous  tissues  were  the  seat  of  a  sort  of  slow  inflammation  ;  and  that  the 
exudation  poured  out  in  the  interstices  of  the  bundles  of  the  fibrous  tis- 
sue gradually  increased  in  amount  as  the  disease  advanced,  and  that  the 
resulting  fibrous  tissue  underwent  condensation  and  contraction,  greatly 
interfering  with  the  action  of  the  tissues  in  question.  The  movements 
of  the  large  joints  at  last  cease  altogether;  this  change  being  partly  due 
to  the  pathological  phenomena  I  have  described,  and  in  part  to  the  cir- 
cumstance that  the  pain  accompanying  every  effort  to  move  has  gradu- 
ally discouraged  the  patient  from  making  any  attempts.  The  limbs 
become  quite  stiff,  and  the  patient  is  dependent  upon  others,  even  for 
every  mouthful  of  food  he  swallows.  We  often  see  extreme  cases  of  the 
kind  in  work-houses  in  the  country.  If  you  visit  some  of  these  institu- 
tions, you  will  almost  certainly  discover  several  persons  who,  for  many 
years,  have  been  complete  cripples  from  rheumatism,  and  are  bedridden 
and  incapable  of  moving  any  one  joint  in  the  body. 

The  inquiry  as  to  the  actual  state  of  things  at  the  seat  of  pain  during 
the  early  stages  of  the  disease  in  ordinary  rheumatic  affection,  is  an  inter- 
esting one,  but  I  am  sorry  to  say  I  cannot  tell  you  what  are  the  essential 
differences  between  a  slightly  rheumatic  and  a  perfectly  healthy  tissue. 
The  facts  of  the  case  justify  the  conclusion  that  certain  materials,  proba- 
bly soluble,  are  formed  in  undue  quantity  in  the  blood — that  the  solu- 
tion transudes  through  the  walls  of  the  capillaries  in  situations  where 
the  vessels  are  few  and  the  circulation  is  slow,  that  the  contact  of  the 
fluid  with  the  fine  ramifications  of  the  nerves  close  to  the  capillaries 
causes  pain,  that  in  consequence  of  the  formation  of  more  fluid  of  the 
same  character  in  the  blood,  that  which  has  been  already  poured  out 
cannot  be  absorbed.  The  accumulation  thus  brought  about  accounts  for 
the  persistent  character  of  the  pain.  Whether  the  pain  is  caused  by  the 
direct  influence  of  the  effused  fluid  on  the  fine  nerve-fibres,  or  upon  the 


196  TREATMENT  OF  RHEUMATISM. 

bioplasm  or  living  matter  connected  with  them,  is  a  question  which  is 
open  to  discussion.  There  can  be  no  doubt  that  stretching  of  the  ter- 
minal ramifications  of  nerve-fibres  or  pressOre  upon  them  will 'give  rise 
to  pain,  and  it  is  not  unreasonable  to  infer  that  fluid  differing  in  its 
composition  from  that  which  bathes  them  in  healiji  would  also  cause 
pain  and  disturbance  of  nerve  action.  The  mere  stretching  and  press- 
ure to  which  the  nerves  are  subjected  are  not,  it  may  be  fairly  objected, 
an  adequate  explanation  in  many  cases,  as  for  instance,  in  those  where 
there  is  persistent  rheumatic  pain  not  associated  with  any  tension  or 
swelling  of  the  tissues.  The  views  above  suggested,  however,  receive 
support  from  the  fact  that  in  many  cases  after  very  free  secretion  has  gone 
on  for  some  time  from  skin,  kidneys,  and  bowels,  the  reabsorption  of 
any  exuded  fluid  does  take  place  and  the  rheumatic  pain  ceases. 

With  regard  to  the  muscles  there  is  almost  invariably  imperfect  action, 
and  some  muscles  during  an  attack  pass  into  a  state  of  complete  inac- 
tion. The  muscular  tissue  which  has  been  many  times  affected  by  the 
rheumatic  state,  gradually  wastes,  and  the  muscle  itself  after  becoming 
very  weak  soon  exhibits  structural  degeneration.  Near  the  tendon  the 
contractile  tissue  undergoes  condensation,  and  slowly  degenerates  into 
fibrous  tissue,  while  in  the  fleshy  parts  adjacent,  fatty  degeneration  often 
occurs.  Shrinking,  wasting,  thickening,  and  contraction  proceed  until 
muscle  after  muscle  deteriorates,  when  the  limbs  fail  to  execute  their 
ordinary  movements.  I  need  hardly  say  more  concerning  the  very  seri- 
ous results  consequent  upon  the  long  continuance  or  frequent  recurrence 
of  the  rheumatic  state.  Every  one  must  see  the  importance  of  doing 
aH  he  can  to  check  the  pathological  changes,  or  failing  this,  to  cause 
them  to  take  place  as  slowly  as  possible,  and  to  retard  the  development 
of  that  dreadful  state  of  helplessness  and  incapacity  which  are  too  often 
the  consequence  of  rheumatism. 

MEASURES  TO  BE  ADOPTED  FOR  THE  TREATMENT  OF  RHEUMATISM. 

General  Hints  concerning  the  Prevention  and  Relief  of  Chronic  Rheu- 
matic Affections. — All  who  suffer  from  rheumatic  pains  should  be  made 
to  understand  that  by  acting  in  a  certain  way  they  may  greatly  diminish 
the  tendency  to  rheumatism  if  they  cannot  completely  check  it,  while  by 
acting  in  a  different  manner  they  may  greatly  encourage  the  progress  of 
the  morbid  change.  All  rheumatics  should  be  instructed  concerning  the 
great  importance  of  promoting  the  free  action  of  the  secreting  organs 
generally.  Their  medical  adviser  should  particularly  direct  their  attention 
to  the  great  importance  of  frequent  and  free  action  of  the  skin,  kidneys, 
and  bowels,  in  order  that  the  materials  which  tend  to  accumulate  in  the 
blood,  and  which  are  concerned  in  the  causation  of  the  rheumatic  state, 
may  be  removed  as  fast  as  they  are  formed,  and  expelled  from  the  system. 

In  our  climate  a  tendency  to  slight  rheumatism  is  so  common  that  I 
should  say  at  least  half  the  population  suffered  more  or  less.  It  is  noticed, 


TURKISH  BATHS.  197 

too,  at  every  period  of  life.  The  so-called  nervous,  neuralgic,  and  mus- 
cular pains  are  very  often  of  a  rheumatic  nature.  These  may  get  well 
of  themselves,  or  be  relieved  or  removed  by  a  purgative,  by  a  few  doses 
of  Bicarbonate  of  Soda  or  Potash,  or  by  one  of  those  effervescing  salines 
now  so  commonly  sold,  or  by  a  few  ordinary  warm  baths,  or,  in  the  case 
of  the  young,  by  active  exercise  followed  by  free  perspiration.  A  some- 
what more  decidedly  developed  rheumatic  condition  often  brings  patients 
to  us  for  advice ;  and  here  and  there,  I  am  sorry  to  say,  we  find  this  to 
be  but  the  state  precursory  to  a  severe  attack.  In  the  great  majority  of 
cases,  however,  the  morbid  condition  yields,  in  a  few  days  or  a  week  or 
two,  to  remedial  measures  based  on  the  principles  already  brought  under 
your  notice. 

The  first  thing  to  bear  in  mind  in  the  treatment,  I  might  say  of  every 
form  of  rheumatism,  is  that  free  action  of  the  skin  should  be  encouraged. 
Warm  baths  of  various  kinds,  and  in-  many  parts  of  the  world,  have  been 
held  in  great  repute  for  their  curative  properties.  The  Turkish  bath  is 
often  of  great  use  to  those  who  are  troubled  with  rheumatic  pains.  It  is, 
however,  a  rather  long  business,  and  the'  patient  who  adopts  it  must  have 
two  hours  or  more  at  his  disposal.  I  know  people  who  take  a  Turkish 
bath  twice  every  week  with  advantage,  and  consider  that  they  could  not 
get  on  without  it. 

Those  who  cannot,  or  will  not,  adopt  the  advice  given  them  to  take 
Turkish  baths  may,  perhaps,  not  object  to  an  ordinary  warm  bath,  twice 
or  three  'times  a  week,  staying  in  the  water  from  twenty  minutes  to  half 
an  hour,  or  until  they  perspire  freely.  I  think  the  action  of  the  ordinary 
warm  bath  in  rheumatism  is  improved  if  the  water  be  made  alkaline. 
This  may  be  done  by  dissolving  in  it  a  quarter  of  a  pound  of  washing- 
soda.  The  vapor  bath  is  also  of  great  use,  and  so  is  the  hot-air  bath. 
Very  simple  arrangements  for  vapor  or  hot  air  may  now  be  obtained. 

By  free  perspiration,  the  removal  from  the  blood  of  a  large  quantity  of 
water  holding  various  substances  in  solution  is  effected.  Thus  thirst  is 
excited.  The  patient  drinks  freely  of  aerated  or  other  water.  In  this 
way  those  noxious  materials  which  would  otherwise  accumulate  in  the 
tissues  are  gradually  removed,  and  the  patients,  perhaps,  escape  much 
suffering. 

Shampooing  is  also  of  great  use  in  slight  cases  of  muscular  and  fibrous 
rheumatism.  By  judiciously  pressing  and  squeezing  the  muscles,  and  by 
rubbing  the  skin,  the  removal  of  fluids  from  the  interstices  of  many  tissues 
is  promoted. 

You  know  it  is  very  important  for  the  free  action  of  the  muscles  that 
the  fluid  which  bathes  the  contractile  tissue,  and  which  undergoes  alter- 
ation during  the  action  of  the  muscl-e,  should  be  frequently  changed.  If 
some  portions  of  the  fluid  remain  in  contact  with  individual  fibres,  the 
materials  resulting  from  the  decomposition  taking  place  during  the  action 
of  those  fibres  will  accumulate  and,  necessarily,  interfere  with  their  free 
17* 


198  REMEDIES  FOR  RHEUMATISM. 

action,  probably  also  affecting  the  action  of  the  nerves,  and  thus  occasion- 
ing rheumatic  pains.  You  will  find  that,  generally,  muscular  pains  may 
be  relieved  by  exciting  the  action  of  the  skin,  the  bowels,  and  the  kid- 
neys. Alkaline  remedies  have  this  effect,  and  are  invariably  useful  to 
those  who  suffer,  perhaps  because  in  this  condition  there  is  an  invariable 
tendency  to  the  development  in  the  system  of  organic  acids,  particularly 
lactic. 

Alkalies  maybe  given  in  all  forms  of  rheumatism.  You  may  order 
Bicarbonate  of  Potash,  or  Liquor  Potasses,  or  Bicarbonate  of  Soda. 
These  are  very  old  remedies,  and  concerning  their  influence  in  relieving 
rheumatic  pains  there  cannot  be  the  slightest  doubt.  In  many  slight 
cases  of  pain,  twenty  or  thirty  grains  of  Bicarbonate  of  Potash,  dissolved 
in  two  ounces  of  water,  will  be  found  to  relieve  in  three  or  four  hours. 
Sal  Volatile  helps  its  action,  and  also  stimulates  the  heart  a  little,  and 
thus  the  blood  is  driven  more  quickly  through  the  capillary  vessels,  and 
absorption  promoted.  You  may  order  the  alkali  to  be  taken  about  half 
an  hour  after  meals,  for  a  week  or  a  fortnight  at  a  time.  But  you  must 
take  care  not  to  let  a  patient  go  on  taking  Liquor  Potasses  or  Bicarbonate 
of  Potash  from  one  year's  end  to  another,  or  you  will  probably  be  con- 
sulted on  account  of  the  appearance  of  phosphates  in  the  urine,  with, 
perhaps,  irritable  bladder.  Retention  of  urine  may  follow,  and  con- 
siderable quantities  of  pus  may  be  formed.  Sometimes  the  patient 
becomes  very  low  and  weak;  and  I  am  not  sure  that  serious  changes  in 
the  blood,  and  even  purulent  inflammation  of  joints,  have  not  resulted 
from  the  too  long  continued  use  of  alkalies.  Potash  and  Soda  are  very 
valuable  remedies,  if  given  with  judgment,  and  if  people  are  not  allowed 
to  go  on  taking  them  as  long  as  they  like.  You  must  not  forget  to  ex- 
plain to  patients  how  long  you  wish  them  to  continue  taking  any  medicine 
you  prescribe,  or  you  will  sometimes  be  astonished,  if  not  alarmed,  to 
find  that  a  somewhat  obedient  patient,  for  whom  you  have  prescribed  a 
pill,  has  been  daily  taking  it  for  years. 

If  a  patient  suffering  from  rheumatism  finds  that  alkalies  disagree  with 
him  and  disturb  his  digestion,  you  may  try  salts  of  vegetable  acids, 
particularly  the  Citrates  and  Tartrates,  for  these  become  converted  into 
alkalies  in  the  system,  and  the  urine  may  even  be  rendered  alkaline  by 
them  as  well  as  by  the  ordinary  alkalies.  Lemon  and  orange  juice,  and 
many  fruits,  also  act  beneficially  in  some  cases. 

Among  diuretics,  the  ordinary  Nitrate  of  Potash  or  Common  Nitre, 
dose  from  five  to  ten  grains,  in  water,  three  or  four  times  a  day;  the 
Acetate  of  Potash,  in  doses  of  from  ten  to  fifty  grains,  in  two  ounces  of 
water,  three  or  four  times  daily;  the  Bitartrate  of  Potash  (Potasscz  Tartras 
Adda],  in  doses  of  twenty  to  sixty  grains  or  more,  in  two  or  three  ounces 
of  water,  three  or  four  times  in  the  twenty-four  hours  (sometimes  also 
acts  as  a  purgative),  and  the  Citrate  of  Potash,  in  the  same  doses  as  the 
Acetate,  are  the  most  generally  useful. 


BROMIDE    OF  POTASSIUM.  199 

Guiacum. — In  former  days,  Guiacum  was  much  in  favor  in  the  treat- 
ment of  chronic  rheumatism,  and  I  have  found  benefit  result  from  its  use. 
You  may  prescribe  the  resin,  Guiaci  Resina,  in  doses  of  ten  grains  made 
into  pills,  or  finely  powdered  and  mixed  with  milk,  three  or  four  times 
a  day,  or  the  Mistura  Guiaci,  an  ounce  of  which  may  be  ordered  twice 
or  three  times  daily.  Perhaps  the  least  unpleasant  form  in  which  to  take 
Guiacum  is  as  the  Ammoniated  Tincture,  Tinctura  Guiaci  Ammoniata, 
in  a  mixture  with  some  bitter  tincture  or  infusion.  Mucilage  and  a  few 
drops  of  Spiritus  Chloroformi,  with  water ;  or  peppermint,  mint,  or  other 
water,  may  be  used  to  cover  the  taste. 

Iodide  of  Potassium. — You  will  often  find  that  severe  lumbago  pain, 
fixed  pains  in  the  muscles  and  fibrous  tissues  in  many  parts  of  the  body, 
and  severe  chronic  aching  about  various  joints,  which  have  troubled 
people  for  months,  will  be  relieved  by  a  few  doses  of  Iodide  of  Potassium 
(Potassii  lodiduni).  You  may  begin  with  three  grains,  three  or  four  times 
a  day,  and  gradually  increase  the  dose  to  five,  six,  eight  or  ten  grains. 
The  Iodide  should  be  dissolved,  in  a  considerable  quantity  of  water,  and 
should  be  taken  about  an  hour  or  more  after  meals.  You  may  also  give 
with  it  half  a  drachm  of  Liquor  Cinchonce  (Battley's),  and  a  few  drops 
of  Tincture  of  Ginger.  Although  I  cannot  justify  the  practice,  on  scien- 
tific grounds,  I  often  give  with  the  Iodide,  Nitrate  of  Potash  (five  grains). 
The  Iodide  probably  acts  upon  the  painful  textures,  partly  by  promoting 
the  absorption  of  exudation,  but  I  think  chiefly  by  taking  the  place  of 
Chloride  of  Sodium,  driving  this  out,  and  thus  promoting  free  circulation 
of  fluids  and  saline  matters  through  the  interstices  of  the  textures.  Don't 
accept  the  conclusion,  implicitly  received  by  many,  that  the  beneficial 
action  of  Iodide  of  Potassium  is  evidence  of  the  syphilitic  origin  of  the 
malady.  This  is  one  of  the  new  delusions.  Some  authorities  attribute 
half  the  ills  we  suffer  from  to  syphilis,  and  even  think  that  a  syphilitic 
taint  accounts  for  the  majority  of  ailments  they  cannot  otherwise  explain 
or  account  for.  If  neither  you  nor  your  father  nor  your  grandfather  had 
syphilis,  the  origin  of  disease  is  to  be  discovered  further  back  in  your 
ancestral  line,  if,  indeed,  it  is  admitted  possible  by  syphilitic  authorities 
that  three'  generations  can  exist  without  having  acquired  the  disease. 
Some  authorities  seem  to  think  that  no  one  exists  who  is  entirely  free 
from  syphilitic  taint.  Both  Iodide  of  Potassium  and  Bichloride  of  Mer- 
cury (from  the  ^  to  the  jg  of  a  grain  for  a  dose)  are  extremely  valuable 
remedies  in  very  many  affections  which  are  not  in  any  way  due  to  syphilis. 

Bromide  of  Potassium,  Potassii  Bromidum,  is  useful  in  cases  in  which 
the  rheumatic  pain  is,  in  part,  neuralgic  in  character.  It  may  be  given 
alone,  or  with  the  Iodide,  in  doses  of  from  ten  to  thirty  grains.  Salicine 
and  Salicylic  Acid  and  Salicylate  of  Soda  (see  p.  191)  are  useful  in  some 
cases  cf  chronic  rheumatism,  and  quinine  is  frequently  of  advantage. 

I  have  observed,  and  in  many  instances,  that  after  the  persistence  of 
slight  but  evidently  rheumatic  pains  for  many  days,  perhaps  for  two 


200  ACTION   OF  THE   SKIN. 

or  three  weeks,  the  patient,  without  resorting  to  any  special  treatment 
whatever,  experiences  unusually  free  action  of  the  skin  at  night.  Even 
in  midwinter,  as  soon  as  he  gets  warm  in  bed,  he  sweats  profusely,  and 
for  the  whole  night, — finding  his  nightshirt  quite  moist  and  his  skin 
thoroughly  soft  and  soddened  in  the  morning,' — although  no  change  had 
been  made  in  his  bedclothes  nor  in  his  diet,  and  he  had  not  taken  any 
medicine  whatever.  The  free  sweating  had  not  only  come  on  of  itself, 
but,  perhaps,  persisted  night  after  night  for  some  time.  So  remarkable 
and  unusual  is  the  free  action  of  the  skin  that  oftentimes  a  patient  is 
alarmed,  and  seeks  advice  with 'the  object  of  stopping  the  cure.  On 
inquiry,  it  is  found  not  only  that  the  rheumatic  pains  have  been  much 
less  severe  since  the  free  sweating  at  night  came  on,  but  that  the  patient 
feels  in  much  better  health.  He  is  in  better  spirits — lighter,  as  he  says — 
and  stronger  and  more  active.  His  mind  clearer.  His  bowels  act  un- 
usually well,  and  his  water  is  excreted  freely,  and  is  perfectly  clear  and 
destitute  of  the  accustomed  sediment.  The  tongue  is  clean  and  the 
appetite  is  good.  But  notwithstanding  his  conviction  that  he  is  in  better 
health  than  usual,  he  fears  the  very  free  sweating  may  weaken  him,  or  in 
some  way  do  harm,  and  therefore  seeks  advice.  Now,  so  far  from  inter- 
fering with  the  free  perspiration,  you  may  assure  your  patient  that  a 
natural  cure  is  being  effected,  and  that  it  is  desirable  not  to  stop  it. 
After  a  week  or  two  the  perspiration  will  diminish,  and  the  patient  will 
feel  well,  and  will  not  be  troubled  with  rheumatic  pains  for  some  time 
to  come.  Such  facts  are  of  the  greatest  interest,  and  are  well  deserving 
of  your  careful  contemplation.  We  may  learn  from  them  even  more  than 
we  can  learn  from  many  serious  cases  of  disease.  And  though,  if  we  act 
rightly,  we  may  object  to  interfere,  our  attention  is  forcibly  directed  to 
certain  phenomena,  from  the  consideration  of  which  the  principle  of 
treatment  to  be  pursued,  in  the  case  of  those  who  are  not  so  fortunate  as 
to  suffer  a  spontaneous  cure,  may  be  deduced. 

Moderate,  but  habitual,  natural  action  of  the  skin,  liver,  and  other 
emunctories,  probably  prevents  altogether  the  development  of  the  rheu- 
matic state.  Free  action  for  a  time  cures  the  rheumatic  condition,  if 
present,  and  this  free  action  may  be  brought  about  by  changes  within 
the  body.  In  the  absence  of  this  action,  however,  we  endeavor  by  arti- 
ficial means  to  excite  it.  And  if  the  rheumatism  is  really  severe,  we 
should  resort  to  the  best  means  we  possess  to  bring  about  these  curative 
influences  as  soon  as  possible. 

Questions  like  the  following  will  doubtless  occur  to  some,  but  I  regret 
to  say  that  I  cannot  adequately  answer  them  :  "  Why  in  some  orgamsms 
only  this  spontaneous  cure  is  observed?  Why  some  never  suffer  from 
rheumatism,  and  so  need  no  cure?  Why  some  suffer  terribly  in  spite 
of  all  measures  adopted  for  their  relief,  and  why  some  die  in  consequence 
of  the  extreme  degree  and  inveterate  character  of  the  rheumatic  phe- 
nomen.4?  "  Some  would  refer  the  difference  to  nerve  action  only,  and 


DIET  IN  RHEUMATISM.  2OI 

there  can  be  no  doubt  concerning  the  amazing  variation  in  rapidity  and 
intensity  of  nerve  action  in  different  individuals.  Some  people  seem  to 
be  "all  nerve."  Others  appear  to  get  on,  and  very  well,  with  extremely 
slow  and  apparently  blunted  nerve  action.  Between  these  two  extremes 
many  degrees  of  difference  are  to  be  noticed.  If  the  nerve  mechanism 
presiding  over  the  physiological  changes  in  the  system  is  well  developed 
and  highly  active,  derangement  will  be  corrected  ere  there  has  been  time 
for  its  existence  to  have  been  made  evident  to  the  consciousness  of  the 
individual ;  but  when  nerves  and  centres  are  dull,  and  small  and  sparse 
in  proportion  to  the  extent  of  area  they  have  to  govern,  response  is  slow, 
and  physiological  derangement  may  even  pass  into  pathological  change, 
and  result  in  structural  alteration  of  a  most  serious  and  irreparable  char- 
acter without  the  patient  being  aware  that  he  is  even  out  of  health.  Nay, 
we  see  the  most  grave  morbid  changes  running  a  long  course,  damaging 
in  the  most  decided  manner,  it  may  be,  many  important  tissues  and 
more  than  one  organ,  and  at  a  comparatively  early  period  of  life,  al- 
though the  patient  has  not  experienced  even  discomfort.  On  the  other 
hand,  sensitive,  constantly  ailing  people  often  lead  long,  complaining 
lives,  and  die  in  old  age,  without  a  single  organ  having  passed  into  a 
state  of  actual  disease.  In  such  instances  as  the  last,  the  patient  is  en- 
dowed with  highly  active  nerve  organs.  In  the  first,  very  decided  patho- 
logical change  fails  to  exert  any  influence  upon  slowly  acting  and  blunted 
nerve  organs.  In  the  one,  broad  and  obvious  lesions  progress  until  action 
is  greatly  deranged  or  death  results ;  in  the  other,  illness  is  prevented 
or  is  self-cured  before  it  progresses  to  any  extent.  Very  decided  and 
well-timed  interference  at  an  early  period,  and  the  utmost  care  all 
through,  would  alone  save  patients  of  the  first  class  from  serious  disease, 
and  perhaps  death  ;  while  no  treatment,  or  only  treatment  of  the  sim- 
plest character,  would  be  needed  by  the  more  sensitive  nervous  person. 
Slight  ailments  in  some  organisms  cause  much  ado,  while  in  others  grave 
pathological  actions  of  great  intensity  may  occur,  and  serious  structural 
morbid  changes  run  their  course  for  a  considerable  time  without  being 
discovered,  and  without  giving  rise  to  any  symptoms  sufficiently  distinct 
to  attract  the  attention  of  the  patient. 

The  Diet  in  Rheumatism  must  be  nutritious,  but  care  should  be  taken 
that  the  patient  does  not  exceed.  All  rheumatics  should  be  careful 
not  to  partake  too  freely  of  meat  and  allied  substances.  Farinaceous 
substances  and  fatty  matters  do  no  harm,  but  while  many  ripe  fruits 
agree  well,  and  some — oranges,  lemons,  cooked  apples,  prunes,  and 
some  others— are  useful,  sugar  in  large  quantity  is  certainly  not  desira- 
ble. Milk  is  excellent,  and  rheumacics  may  take  it  in  quantity.  Vari- 
ous puddings,  such  as  batter,  sago,  tapioca,  etc.,  made  with  milk  and  an 
egg,  may  be  recommended.  Acid  wines,  like  the  commoner  forms  of 
claret,  often  do  harm,  and  indeed  may  occasion  rheumatic  pains.  Beer 
is  especially  hurtful,  and  should  invariably  be  withheld.  In  treating 


202  OF  CATCHING   COLD. 

cases  of  rheumatism  you  must  impress  upon  patients  very  strongly  that 
beer,  as  well  as  claret  and  some  acid  wines,  seriously  interferes  with  the 
improvement  which  otherwise  would  probably  result  from  the  remedies 
you  prescribe.  If  stimulants  are  required  at  all,  you  may  allow  in  the 
twenty-four  hours  two  or  three  tablespoonfuls  of  brandy  with  seltzer  or 
other  mineral  water,  or  the  same  quantity  of  whiskey  with  lemon  juice 
and  water. 

Importance  of  Warmth  and  Warm  Clothing. — Cold,  damp,  ill-venti- 
lated rooms  are  especially  hurtful,  and  exposure  to  sudden  changes  of 
temperature  often  gives  rise  to  very  severe  and  acute  attacks  of  rheuma- 
tism. Those  who  are  prone  to  'rheumatism  may  feel  annoyed  if  they 
perspire  much,  and  are  too  often  unwise  enough  to  try  to  check  the  ten- 
dency to  perspiration  by  wearing  very  light  clothing,  and  thus  not  uncom- 
monly they  precipitate  an  attack.  Not  only  should  all  persons  who  have 
even  a  slight  tendency  to  rheumatism  wear  woollen  next  the  skin  during 
the  day,  but  at  night  they  should  either  have  a  flannel  night-dress  or  a 
flannel  jacket  over  their  cotton  garment.  If  the  shoulders  and  arms  be 
exposed  at  night  with  insufficient  covering,  very  obstinate  rheumatic  pain, 
which  may  last  a  considerable  time,  is  sometimes  the  consequence. 

A  departure  from  the  healthy  state  of  the  blood  may  originate  either 
in  the  circulating  fluid  itself,  or  may  be  determined  by  changes  in  the 
tissues  and  organs  which  it  nourishes.  The  change  in  the  blood  may,  in 
its  turn,  react  upon  and  influence  the  action  of  some,  and,  indeed,  almost 
all  the  tissues  and  organs  in  the  body.  When  this  is  the  case,  the  phe- 
nomena are  said  to  be  "general,"  to  distinguish  them  from  phenomena 
of  the  same  general  nature  which  are  restricted  in  area,  and  are  spoken 
of  as  "  local."  We  may  speak  of  general  tissue  changes,  general  fever, 
general  inflammation,  as  contrasted  with  changes  of  phenomena  similar 
in  their  nature,  but  which  are  local,  and  affect  only  a  very  small  portion 
of  the  body.  Among  the  most  important  and  most  common  general 
changes  are  those  departures  from  healthy  action  known  as  fevers  and 
general  inflammations.  So  common  is  febrile  and  inflammatory  disturb- 
ance that  it  is  doubtful  whether  a  single  example  could  be  adduced  of  a 
mammalian  organism  which  had  reached  maturity  without  having  suf- 
fered more  or  less  from  some  such  pathological  changes.  Few  of  us  pass 
a  month  without  experiencing,  in  our  own  bodies,  some  degree  of  febrile 
or  inflammatory  disturbance,  and  many  are  seldom  entirely  free  for  many 
weeks  at  a  time  from  phenomena  of  the  kind. 

Of  Catching  Cold. — Before  bringing  under  your  notice  the  actual  phe- 
nomena which  characterize  all  fevers  and  inflammations,  I  propose  to 
direct  attention  to  the  consideration  of  that  most  common  of  all  febrile 
disorders,  and  the  best  known  of  all  slight  ailments — an  ordinary  cold — • 
in  the  course  of  which  a  certain  degree  of  febrile  and  inflammatory  action 
invariably  occurs. 

Most  people  have  ''caught  cold  "  probably  many  times  in  the  course 


ACTUAL    CHANGES  IN  CATCHING   COLD.  203 

of  their  lives,  and  though  they  may  have  suffered  on  some  occasions 
severely,  there  is  no  reason  to  suppose  that  any  tissue  in  the  body  has 
been  damaged  in  the  slightest  degree,  or  that  any  Structural  disease  has 
resulted  in  consequence.  Whenever  you  are  unfortunate  enough  to  take 
cold,  you  should  make  the  most  of  the  opportunity,  and  carefully  study 
the  changes  as  they  go  on  in  your  own  organism. 

When  the  cold  is  coming  on,  you  may  perhaps  shiver  a  little,  or  you 
may  experience  a  creeping  sensation,  apparently  in  the  skin  of  different 
parts  of  the  body.  Although  you  may  feel  quite  chilly,  if  you  place  a 
clinical  thermometer  in  your  arm-pit,  you  will  be  surprised  to  discover 
that  it  indicates  a  rise  of  three  or  four  degrees  above  the  normal  in  the 
temperature  of  your  body,  and  the  very  striking  and  important  fact  will 
be  impressed  upon  you  that,  although  you  feel  extremely  chilly  and  in- 
clined to  shiver,  and  desire  warm  clothing,  or  to  sit  by  the  fire,  with  a 
good  blanket  over  you,  the  temperature  of  the  body  is  decidedly  higher 
than  it  ought  to  be,  and  in  fact  may  have  risen  from  a  little  under  98° 
Fahrenheit,  the  point  at  which  it  stands  in  health,  to  100°,  101°,  or  102°. 
You  need  not  be  very  much  disturbed  or  frightened  if  you  should  find 
that  it  marks  103°.  You  will  also  notice  that,  as  soon  as  you  get  into  a 
free  perspiration,  all  the  uncomfortable  sensations  which  you  have  expe- 
rienced during  perhaps  several  hours,  will  disappear.  If,  as  soon  as  you 
feel  warm,  and  especially  if  you  have  perspired  a  little,  you  again  use 
the  thermometer,  you  will  find  that  the  temperature  has  fallen  a  degree 
or  two.  After  you  have  perspired  very  freely,  it  will  fall  lower  still,  and 
probably  stand  at  the  normal. 

I  shall  endeavor  to  show  not  only  that  a  cold  is  a  form  of  fever,  but 
that  in  many  colds  there  is  evidence  of  a  certain,  and  in  some  a  consid- 
erable, degree  of  inflammatory  action.  The  mucous  membrane  of  the 
nasal  passages,  of  the  larynx,  trachea,  and  bronchial  tubes,  of  the  pharynx, 
and  many  of  the  small  glands  connected  with  these  surfaces,  are  red  and 
"inflamed."  The  capillary  circulation  in  them  is  impeded,  and  if  a 
minute  examination  be  made  we  shall  find  evidence  of  undue  growth 
of  the  bioplasm  of  the  epithelium  and  adjacent  structures. 

Many  of  the  symptoms  which  usher  in  an  ordinary  cold  precisely 
resemble  those  which  occur  when  some  special  form  of  fever  or,  it  may 
be,  severe  inflammation  is  about  to  attack  the  patient.  In  the  last  case 
the  shivering  and  other  phenomena  may  be  more  severe,  but  the  differ- 
ence is  one  of  degree;  in  fact,  a  cold  must  be  included  among  the  Fe- 
brile Diseases. 

But  let  us  for  a  moment  go  further  back  in  our  inquiry  as  to  the  nature 
of  the  malady,  and  try  to  discover  the  change  which,  so  to  say,  consti- 
tutes the  first  departure  from  the  normal  state  in  the  case  of  a  common 
cold  or  other  simple  form  of  febrile  attack.  The  event  in  question  usu- 
ally precedes  by  hours,  and  it  may  be  days,  the  manifestation  of  any 
symptoms.  The  actual  process  of  taking  cold  is  never  immediately  fol- 


IMPORTANCE    OF  EXCRETION. 

lowed  by  any  phenomena  which  disturb  the  health  or  which  indicate  to 
the  patient  himself  that  he  has  passed,  or  is  about  to  pass,  from  the 
healthy  into  an  abrformal  state.  This  fact  alone — the  existence  of  an 
interval  between  the  commencement  of  the  operation  of  the  disturbing 
cause  and  the  development  of  distinct  derangement  in  the  physiological 
actions  of  the  body— Lseems  sufficient  to  show  that  the  symptoms  are  not 
due  to  nervous  disturbance  alone,  and  conclusively  points  to  the  conclu- 
sion that  the  change  excited  is  of  such  a  nature  that  it  does  not  result  in 
immediate  consequences. 

The  condition  of  the  organism  which  favors  "  taking  cold  "  is  not  one 
of  perfect  health.  The  circulation  at  the  time  is  feeble,  and  the  blood 
itself  not  in  a  perfectly  healthy  state.  Instead  of  passing  quickly  through 
the  cutaneous  capillaries,  the  circulation  is  retarded  in  the  surface-vessels, 
partly  on  account,  as  above  suggested,  of  feeble  heart's  action,  but  mainly, 
I  think,  owing  to  the  muscular  fibres  of  the  smallest  arteries  being  re- 
laxed, and  the  consequent  dilatation  of  the  tube  of  the  vessel.  The  blood, 
very  slowly  traversing  the  cutaneous  capillaries,  being  far  too  long  a  time 
exposed  to  the  cooling  influences  perhaps  of  a  draught  of  cold  air, 
becomes  the  seat  of  chemical  changes  which  differ  from  those  ordinarily 
taking  place  in  the  blood  constituents.  The  particular  chemical  com- 
pounds formed  under  these  circumstances  are  not  readily  excreted. 
Remaining  in  the  blood,  they  accumulate,  and  minute  bioplasts  grow 
and  multiply.  At  length  an  influence  upon  the  nerves  is  exerted,  and 
then  ensues  the  chilliness  and  other  symptoms  due  to  the  derangement 
of  the  action  of  many  tissues  and  organs  of  the  body  which  mark  the 
invasion  of  the  illness.  After  a  time 'the  materials  in  question  begin  to 
be  eliminated,  and  the  patient  gets  well. 

If  we  promote  the  action  of  the  excreting  organs,  we  follow  the  "sug- 
gestions of  nature"  and  expedite  recovery.  Now  some  may  think  all 
this  a  rather  fanciful  explanation  ;  but  if  we  consider  what  happens  in 
slight  rheumatism,  we  shall,  I  think,  be  convinced  that  the  conclusions 
arrived  at  are  supported  by  facts.  When  the  rheumatic  state  comes  on, 
the  patient  experiences  pain  in  the  muscles  and  fibrous  tissues  in  many 
parts  of  the  body  distant  from  one  another,  which  pains  are  relieved 
in  a  very  short  time  if  free  action  of  the  skin,  kidneys,  and  bowels  is 
established.  There  is  no  doubt  whatever  that  certain  alkaline,  diuretic, 
and  purgative  medicines  excite  the  desired  action,  and  thus  the  morbid 
condition  is  relieved  or  cured.  The  increased  flow  of  urine,  caused  by 
giving  diuretics,  is  followed  by  thirst,  to  quench  which  the  patient  resorts 
to  cooling  drinks.  Thus  the  tissues  get  well  washed  out,  and  the  peccant 
materials  which,  by  their  action  on  the  nerves,  cause  the  pain,  are  by 
degrees  highly  diluted  and  dissolved  away,  or  in  the  blood  are  con- 
verted into  materials  which  are  readily  removed  from  the  body  by  different 
emunctories.  We  have  thus  accounted  for  the  formation  of  morbid 
materials  in  the  body,  and  have  explained  how  these  derange  many 


SYMPTOMS   OF  A    COLD. 

physiological  actions  and  occasion  pathological  phenomena.  Further, 
it  has  been  shown  how  these  noxious  substances  are  removed,  and  by 
what  means  their  removal,  or,  in  other  words,  the  recovery  of  the  patient, 
may  be  assisted  and  hastened. 

Preliminary  Changes  and  Attendant  Phenomena. — As  regards  the 
accession  of  a  cold,  or  other  febrile  or  inflammatory  attadk,  the  first 
indications  of  derangement  in  the  ordinary  physiological  processes  are 
much  the  same ;  but  the  intensity  of  the  changes  varies  greatly  in  different 
fevers  and  inflammations.  For  some  little  time  before  you  "  catch  cold," 
you  are  conscious  of  not  being  in  the  ordinary  state  of  health.  Without 
feeling  very  weak  or  low,  you  are  inclined  to  lie  down  ;  and,  perhaps, 
if  you  followed  your  own  inclination,  you  would  go  to  bed,  and  in  this 
way  try  to  obtain  relief  from  the  discomfort  and  sense  of  oppression  and 
general  uneasiness.  In  a  short  time  some  degree  of  soreness  about  the 
nose  is  usually  experienced,  and  this  is  often  associated  with  dryness  of 
the  nasal  cavity  and  of  the  throat.  The  tongue  feels  more  or  less  dry 
and  uncomfortable.  Little  or  no  saliva  is  secreted  ;  the  skin,  too,  often 
feels  hot  and  dry.  When  the  skin  is  perfectly  healthy,  it  is  smooth  and 
supple,  but  when  a  cold,  or  any  general  fever  or  inflammation,  is  coming 
on,  a  change  usually  takes  place.  It  becomes  more  or  less  harsh,  and  even 
rough,  small  particles  of  the  outer  layer  of  the  cuticle  being  partially 
detached.  The  surface,  in  consequence,  feels  dry  and  rough,  and  when 
rubbed,  bran-like  particles,  consisting  of  the  scales  of  old  cuticle,  are 
removed. 

Very  frequently  the  patient  experiences  slight  uneasiness  about  the 
head,  perhaps  not  amounting  to  actual  headache,  but  a  little  pain,  it  may 
be,  over  the  brow,  or  heaviness  there  or  at  the  back  of  the  head,  or  in 
the  back  of  the  neck,  or  in  all  these  situations.  The  pain  in  the  neck  is 
probably  caused  by  some  derangement  affecting  the  nerves  distributed 
to  those  muscles  by  the  action  of  which  the  head  is  raised  and  drawn 
backwards.  This  pain  just  below  the  occiput  often  lasts  for  several 
days  and  is  very  troublesome,  the  slightest  movement  of  the  head  being 
difficult  in  consequence  of  the  pain  which  is  excited. 

When  a  cold  or  fever  is  imminent,  you  usually  feel  weak  and  disin- 
clined to  take  exercise.  If  it  is  necessary  to  walk,  you  have,  as  it  were, 
to  force  yourself  to  do  so.  There  is  little  appetite,  and  perhaps  no 
desire  to  eat  an  ordinary  meal.  Rather  than  solid  food,  you  feel  inclined 
to  take  a  cup  of  warm  soup  or  strong  beef-tea,  or  ordinary  tea  or  coffee, 
or  gruel,  or  hot  wine  and  water.  There  is  very  generally  indeed  a 
demand  for  fluid  when  a  cold  is  coming  on.  You  feel  dry  and  thirsty, 
and  almost  instinctively  seek  for  water,  iced  water,  or  lemonade.  It  is 
unquestionably  advantageous  to  take  fluids  when  these  sensations,  which 
usher  in  a  cold  in  the  head  or  other  febrile  attack,  are  experienced. 
For  although,  as  Dr.  J.  C.  B.  Williams  long  ago  showed,  by  resisting 
the  longing  for  fluid,  and  bearing  with  the  thirst  for  two  or  three  days, 
18 


2O6  BODY-HEAT  OF  MAN. 

the  catarrhal  symptoms  may  be  lessened,  at  least  for  a  time,  the  dis- 
comfort and  distress  are  often  so  great  that  the  patient  prefers  the  in- 
convenience incidental  to  the  cold  to  the  suffering  which  results  from 
carrying  out  this  dry  system  of  treatment  for  its  relief  or  cure,  and  it  is 
doubtful  whether  the  duration  of  the  illness  is  by  this  plan  in  any  way 
shortened.  I  have  thought  that  in  some  cases  the  cold  has  been  cut 
short  by  taking  plenty  of  fluid,  and  thereby  exciting  free  action  of  the 
skin  and  kidneys.  The  premonitory  symptoms  of  a  cold  are  unques- 
tionably often  much  relieved  by  a  basin  of  hot  soup,  or  even  warm  tea 
or  coffee.  As  you  are  probably  aware,  the  treatment  everywhere  most 
popular  is  a  glass  of  hot  wine  or  spirits  and  water.  You  will  hear  in 
every  part  of  the  country  of  cases  of  various  terrible  forms  of  disease 
which  have  been  at  once  stopped  or  cut  short  by  a  stiff  glass  of  hot 
brandy,  whiskey,  or  gin  and  water.  Although  the  secretion  from  the 
mucous  membrane  may  be  diminished  by  withholding  fluid  for  a  time, 
it  is  also  quite  certain  that  general  relief  of  the  discomfort  and  unpleas- 
ant symptoms  may  be  obtained  from  the  very  opposite  system,  that  of 
drinking  freely  of  fluids  which  excite  the  action  of  the  skin  and  kidneys, 
and  thus  wash  out  of  the  system  various  deleterious  matters  which  have 
accumulated  in  the  blood. 

The  Body-heat  of  Man  and  Warm-blooded  Animals  Fixed  and  Defi- 
nite.— The  temperature  of  man  and  the  higher  animals  in  a  state  of  health 
is  fixed  within  a  very  limited  range,  and,  as  I  mentioned  in  one  of  my 
early  lectures,  it  is  worthy  of  note  that  this  fixed  and  definite  tempera- 
ture of  the  blood  in  the  case  of  warm-blooded  animals  is  maintained  at 
the  uniform  standard,  although  the  temperature  of  the  medium  in  which 
the  animal  lives  may  vary  greatly  from  time  to  time.  The  temperature 
of  our  body  is  the  same  in  summer  and  winter,  or  at  the  most  varies 
little  more  than  a  degree  of  Fahrenheit's  scale.  A  man  in  the  polar 
regions  will  have  the  same  internal  temperature  as  one  living  at 'the 
equator.  In  the  cold  climate  there  is  very  little  sensible  perspiration. 
In  the  hot  one  perspiration  never  ceases,  and  the  cuticle  is  always  wet 
and  soddened.  By  constant  changes  in  the  rate  at  which  heat  is  evolved 
in  and  carried  off  from  the  body,  the  internal  temperature  of  the  blood 
is  kept  very  nearly  uniform.  It  is  remarkable  that  the  limit  of  variation 
in  health  is  so  slight,  for  we  may  regard  it  as  proved  that  -the  blood 
cannot  vary  to  a  greater  extent  than  is  represented  by  two  degrees  of 
Fahrenheit,  without  a  departure  from  the  normal  state  of  health. 

Whether  the  air  be  cold  or  hot,  whether  a  person  take  violent  exer- 
cise or  lie  quietly  in  a  warm  bed,  whether  food  be  taken  frequently  or 
withheld  for  many  hours,  the  temperature  will  not  exhibit  more  than  a 
very  slight  temporary  disturbance,  and  whenever  a  change  does  occur, 
the  temperature  will  very  soon  return  to  the  normal  point. 

Rise  of  the  Body-heat  in  all  Fevers  and  Inflammations. — In  every 
form  of  fever  and  in  every  kind  of  inflammation  the  temperature  of 


INCREASED  OXIDATION  IN  FEVER  AND  INFLAMMATION.     2O/ 

the  body  or  of  the  affected  part,  and  therefore  the  blood,  rises.  You 
must  not  forget  that,  although,  as  I  have  said,  the  patient  may  feel  ex- 
cessively chilly,  nay,  though  he  be  seized  with  decided  rigors,  so  that  he 
is  excessively  pallid,  the  face  being  pinched  and  destitute  of  color,  or 
actually  livid  and  cold  to  the  touch,  his  limbs  trembling  and  his  teeth 
chattering,  the  temperature  of  his  blood  will  be  higher  than  in  the 
ordinary  condition  of  health.  So  far  from  the  blood  being  entirely  or 
only  affected,  it  is  more  probable  that  in  many  cases  the  rise  in  temper- 
ature begins  in  the  tissues  outside  the  vessels.  The  blood-corpuscles,  as 
they  pass  through  the  capillaries,  take  heat  from  one  place  and  distribute 
it  to  other  parts,  so  that  a  considerable  rise  in  one  spot  may  be  soon 
reduced,  and  the  heat  diffused  over  a  wide  area,  and  thus  cause  a  slight 
•rise  in  the  temperature  of  the  body  generally.  Even  in  the  flea-bite,  if 
it  were  possible  to  place  an  instrument  among  the  distended  capillaries 
and  tissues  of  the  affected  part,  the  temperature,  I  venture  to  say,  would 
be  found  higher  than  in  the  tissues  just  beyond  the  affected  area.  In 
extensive  inflammations,  as  was  shown  by  Mr.  Simon,  the  temperature 
of  the  blood  which  leaves  the  inflamed  part  is  always  decidedly  higher 
than  when  it  passes  into  it. 

There  is  not  a  fever  known  to  us  in  which  the  temperature  does  not 
rise  above  the  normal ;  neither  is  there  any  inflammation  which  is  not 
characterized  by  phenomena  which  occasion  the  development  of  an 
increased  degree  of  heat  in  the  inflamed  part.  This  generalization  is  to 
be  extended  to  all  the  higher  animals.  Every  creature  capable  of 
suffering  inflammation  or  the  feverish  condition  exhibits,  during  the 
attack,  elevation  of  temperature.  There  is,  in  fact,  a  very  intimate  con- 
nection between  the  increased  development  of  heat  and  the  states  Fever 
and  Inflammation,  and  we  may  go  so  far  as  to  affirm  that  the  existence 
of  either  of  these  pathological  processes  without  a  rise  in  the  tempera- 
ture is  not  possible.  In  both  fever  and  inflammation  it  would  seem  that 
the  circumstances  which  determine  the  maintenance,  of  the  equable 
body-heat  of  health  are  deranged,  either  generally,  as  in  the  fever,  or 
locally,  as  in  the  inflammation.  Heat  is  developed  faster  than  it  can  be 
carried  off,  or  the  processes  by  which  it  is  carried  off  are  for  the  time 
interfered  with,  or  both  circumstances  are  concerned  in  determining  the 
rapid  rise  of  temperature  which  is  often  observed  in  various  fevers  and 
inflammations  of  marked- intensity. 

Is  there  Increased  Oxidation  in  Fever  and  Inflammation? — This 
question  is  one  of  much  importance  in  reference  to  the  consideration  of 
the  real  nature  of  the  febrile  condition.  It  would  be  answered  directly 
and  most  positively  in  the  affirmative  by  most  pathologists,  but,  as  we 
shall  see,  the  facts  known  by  no  means  justify  an  off-hand  and  confident 
answer.  The  secretion  from  the  kidneys  of  a  person  suffering  from 
feverishness  is  usually  concentrated  and  of  high  specific  gravity.  You 
will  frequently  find  it  loaded  with  urates,  and  often  there  will  be  Excess 


208     INCREASED  OXIDATION  IN  FEVER  AND  INFLAMMATION. 

of  Urea.  Deposits  of  uric  acid  are  common.  The  Excess  of  Ure.a  is 
shown  in  a  very  simple  way.  To  about  half  a  teaspoonful  of  the  urine 
in  a  test-tube  you  add  an  equal  bulk  of  strong  nitric  acid,  and  plunge 
the  lower  part  of  the  tube  at  once  into  cold  water,  shaking  it  from  time 
to  time.  In  the  course  of  a  few  minutes  crystals  of  Nitrate  of  Urea  will 
begin  to  form,  and  if  the  specific  gravity  of  the  urine  is  1.030  or  higher, 
it  may  become  almost  solid  from  the  quantity  of  crystals  formed. 

The  circulation  of  the  blood  and  the  action  of  the  various  organs  in 
the  body  are  greatly  disturbed,  and  there  is  departure  from  the -normal 
state  in  many  respects,  both  as  regards  the  chemical  processes  going  on 
in  the  blood,  and  the  presence  and  accumulation  in  quantity  in  the 
circulating  fluid  of  substances  which  ought  to  be  removed  from  it  in  a 
very  dilute  state  as  fast  as  they  are  formed  and  passed  into  it.  Instead 
of  this,  many  of  the  excrementitious  matters  are  in  such  a  high  degree 
of  concentration  that  they  readily  separate  from  the  fluid  in  which  they 
are  dissolved,  and  in  the  case  of  the  urine  some  are  deposited  soon  after 
the  secretion  has  been  passed  and  has  become  cool. 

These  and  many  other  phenomena,  which  are  undoubtedly  due  to 
exceptional  chemical  change,  are  often  set  down  to  excessive  oxidation, 
although  a  careful  consideration  of  the  facts  would  lead  us  to  entertain 
the  opposite  conclusion,  that  oxidation  was  deficient  instead  of  being  in 
excess. 

In  many  books  you  are  told  that  body-heat  is  invariably  the  result  of 
the  combination  of  carbon  and  other  elements  with  oxygen — that  the 
increase  of  temperature  in  all  fevers  is  due  to  increased  oxidation. 
There  is,  however,  evidence  of  a  most  striking  kind  that  in  various 
morbid  conditions  in  which  the  temperature  of  the  body  considerably 
exceeds  the  normal  standard  the  process  of  oxidation  is  much  interfered 
with.  If,  for  instance,  a  man  has  one  lung  solid  from  the  air-cells  being 
plugged  up  with  lymph  poured  out  from  the  blood,  as  occurs  in  pneu- 
monia, is  it  not  unreasonable  to  maintain  that  oxidation  is  going  on 
to  a  greater  extent,  or  is  more  complete,  than  in  health?  In  this  case 
are  not  the  air-cells  filled  with  solid  matter,  which  renders  the  entrance 
of  air  less  constant  and  its  renewal  quite  impossible  ?  And  yet  we  are 
assured  that  the  elevation  of  temperature  in  pneumonia,  and  in  all  other 
febrile  and  inflammatory  states,  is  due  to  increased  oxidation,  and  to  that 
alone.  Again,  the  body  of  a  person  who  has  died  from  a  terribly  severe 
attack  of  acute  rheumatism  can  hardly  be  considered  to  be  in  a  state 
favorable  to  free  oxidation.  Nevertheless  the  temperature,  which  at 
the  time  of  death  may  be  as  high  as  107°  or  108°,  often  rises  three  or 
four  degrees  of  Fahrenheit  during  the  first  hour  or  two  after  death. 
How,  then,  can  we  reasonably  attribute  this  rise  of  temperature  to  in- 
creased oxidation  ?  Consider  not  only  that  the  rise  continues  for  some 
time  after  the  lungs  have  ceased  to  act  at  all,  and  the  heart  can  no  longer 
propel  a  drop  of  blood  along  the  vessels,  but  that  for  many  hours,  or 


ASCERTAINING    THE    TEMPERATURE.  2Op 

even  days,  before  death  the  conditions  of  the  system  had  been  most 
unfavorable  to  the  introduction  of  air  and  its  free  distribution  to  distant 
parts,  as  also  to  its  absorption  by  the  tissues  and  fluids.  We  can  show 
that  in  all  probability  the  high  temperature  is  due  to  the  increased 
growth  of  bioplasm,  not  to  increased  oxidation. 

The  generalization  that  the  elevation  of  temperature  in  fever  and 
inflammation  is  due  to  increased  oxidation  is,  I  think,  a  grave  mistake. 
It  is  more  probable  that  the  phenomenon  is  occasioned  by  changes  in 
the  bioplasm  or  living  matter  of  the  blood  and  tissues  of  a  nature  far 
removed  from  the  process  of  oxidation.  I  shall  have  again  to  refer  to 
this  very  interesting  subject,  and  hope  to  consider  it  more  in  detail. 

Method  of  Ascertaining  the  Temperature  of  the  Body. — The  actual 
temperature,  as  indicated  by  the  thermometer,  is  found  to  vary  slightly, 
according  to  the  part  of  the  body  which  is  selected  for  observation.  If, 
'for  example,  you  place  the  thermometer  under  the  tongue,  you  wi'l  find, 
as  you  would  anticipate,  that  it  will  mark  a  degree  or  so  higher  than  if 
the  same  instrument  is  placed  in  the  arm-pit.  In  medical  observations 
on  the  body-heat  we  restrict  ourselves  to  observations  in  two  places, 
the  mouth  underneath  the  tongue  and  the  arm-pit.  But  if  you  try  the 
mouth,  in  the  case  of  children,  you  will  not  unfrequently  have  the  bulb  of 
your  instrument  bitten  off.  Such  an  accident  is  serious,  for  good  clinical 
thermometers  cost  from  twelve  to  sixteen  shillings  each.  It  is,  therefore, 
upon  the  whole,  better  to  take  the  temperature  in  the  arm-pit  only.  In 
order  that  you  may  be  able  to  compare  the  records  of  different  cases, 
you  must  take  care  to  work  in  precisely  the  same  way,  and  to  place  the 
thermometer  in  the  arm-pit  for  at  least  two  minutes,  if  the  bulb  is  a  very 
small  one,  and  for  double  that  time  if  it  is  not  of  the  smallest  size.  You, 
will  have  little  difficulty  in  using  the  small  thermometer,  even  in  the 
case  of  the  most  irritable  and  violent  children ;  for  you  can  always  put 
it  in  the  arm-pit  and  keep  the  child's  arm  nearly  still  for  the  length  of 
time  required. 

Thermometers  for  medical  observation,  clinical  thermometers  as  they 
are  called,  maybe  obtained  of  all  the  instrument  makers.  Those  with  the 
smallest  bulbs  respond  very  quickly,  and  the  index  comes  to  a  stand  in 
two  minutes,  or  even  in  less  time ;  but  the  degrees  are  small  and  more 
difficult  to  read  off  than  those  of  larger  instruments,  which  require  to  be 
inserted  in  the  arm-pit  for  four  or  more  minutes  before  you  can  feel  sure 
that  the  mercury  has  come  to  a  standstill.  Of  late  a  great  improvement 
has  been  made  in  the  construction  of  the  very  small  thermometers.  The 
bore  is  so  fine  that  observers  whose  eyesight  is  not  the  most  perfect 
often  find  it  difficult  to  see  the  index.  By  grinding  the  glass  away 
somewhat  at  the  sides  and  making  the  front  of  a  greater  convexity,  the 
effect  of  an  elongated  lens  is  produced,  and  the  almost  invisible  mer- 
curial thread  is  made  to  appear  as  a  broad  band  of  mercury,  which  can 
be  seen  without  the  slightest  difficulty. 
18*  O 


2IO  COLD,  HOT,  AND   SWEATING  STAGE. 

Further  Consideration  of  the  Essential  Phenomena  of  Fever  and 
Inflammation — Rigors  and  Cold  Stage — Hot  Stage — Sweating  Stage. — 
When  a  severe  form  of  fever  or  inflammation  is  about  to  attack  a  patient, 
instead  of  mere  chilliness  and  a  sensation  of  creeping  or  tingling  of  the 
surface  skin,  an  actual  rigor  is  experienced.  This  is  often  so  intense 
that  the  patient  trembles  in  every  limb,  his  teeth  chatter,  and  he  feels 
dreadfully  ill.  The  very  bed  on  which  he  lies  may  be  perceptibly  shaken, 
so  violent  and  so  general  is  the  nerve  and  muscular  disturbance. 

Among  severe  inflammations,  a  sharp  attack  of  inflammation  of  the 
lungs,  Pneumonia,  and  among  fevers,  small-pox,  Variola,  and  scarlet 
fever,  Scarlatina,  are  ushered  in  thus.  If  you  were  called  to  the  patient 
as  soon  as  he  was  taken  ill,  you  would  see  his  limbs  trembling  violently, 
his  face  pale  and  anxious,  the  patient  himself  would  be  considerably 
depressed,  suffering  from  nausea,  and  probably  every  now  and  then 
violent  retching  would  add  to  his  distress.  If  you  put  your  hand  on  his 
pulse,  you  find  it  quick,  feeble,  and  small;  and  if  you  place  the  ther- 
mometer in  his  axilla,  you  will  find  the  temperature  higher  than  normal, 
perhaps  by  four  or  five  degrees. 

It  would  seem  that  the  blood  is  diverted  from  the  general  surface  of 
the  body,  and  is  driven  in -greater  proportion  to  internal  parts — to  the 
lungs,  to  the  intestines,  to  the  liver,  and  to  other  internal  organs.  These 
preliminary  symptoms,  with  the  shivering  which  is  developed  in  a  re- 
markable degree,  represent  what  is  known  as  the  "cold  stage"  of  an 
'•'  intermittent  fever."  Ague  is  a  very  remarkable  form  of  feverish  attack, 
inasmuch  as  the  several  special  stages  which  are  to  be  traced  with  more 
or  less  distinctness  in  all  fevers  and  inflammations  are  very  manifest, 
and  are  well  defined  and  sharply  marked  off  from  one  another.  In 
the  cold  stage,  blood  not  only  leaves  the  surface,  but  temporarily  parts 
with  much  of  its  water,  which  then  occupies  the  interstices  of  the  tissues. 
After  a.  time  it  again  enters  the  blood  or  passes  off  by  the  intestines,  in 
which  case  it  may  be  altogether  removed  from  the  body,  as  in  Diarrhoea, 
or  in  Cholera,  in  which  disease  the  blood  becomes  of  a  thick  and  tarry 
consistence,  and  stagnates  in  many  of  the  vessels,  scarcely  moving  at 
all  in  some  of  the  capillaries  which  are  distributed  to  very  important 
organs  of  the  body. 

The  shivering  and  other  symptoms  which  constitute  the  first  indica- 
tions of  derangement  in  febrile  diseases  are  referable  to  conditions 
favoring  the  formation  of  deleterious  matters  in  the  blood  itself.  In 
some  cases  these  are  due  to  changes  originating  in  the  organism,  in 
others  to  the  introduction  of  a  poison  from  without. 

The  phenomena  which  mark  the  accession  of  a  common  cold  corre- 
spond to  the  cold  stage  of  the  ague-fit.  I  think  it  probable  that  the 
so-called  collapse  stage  of  cholera  is  also  analogous  to  the  first  stage  of 
the  ague-fit,  and  consider  that  it  represents,  only  in  the  most  severe  form, 
the  general  phenomena  which  usher  in  every  form  of  febrile  and  inflam- 


FEVER  IN  CHOLERA.  211 

matory  attack.  It  is  in  a  sudden  and  very  severe  attack  of  this  most 
terrible  disease,  Cholera,  that  we  see  the  cold  stage  of  a  fever  in  its 
highest  conceivable  degree  of  development ;  for,  in  fact,  the  collapse  is 
so  severe  and  so  widely  diffused,  so  manifestly  deranging  the  action  of 
every  tissue  and  organ  in  the  body,  that  in  too  many  instances  death 
results  in  a  very  short  time.  But  Cholera,  like  other  febrile  affections, 
has  not  only  its  cold  stage.  If  the  patient  lives,  the  terrible  state  of 
collapse  at  length  gives  place  to  great  heat  and  dryness  of  skin,  and  this 
hot  stage  in  turn  is  followed  by  a  crisis  or  critical  change,  when  .the 
kidneys  and  skin  again  resume  action.  The  blood  regains  its  color 
and  begins  to  freely  flow  along  its  accustomed  channels,  and  the  various 
glands  and  tissues  gradually  recover  from  the  shock  they  have  suffered 
and  return  to  their  normal  state.  The  patient,  in  fact,  soon  becomes 
convalescent. 

The  feverish  condition  which  in  cholera  follows  the  stage  of  collapse, 
after  a  varying  interval  of  time,  is  called  Secondary  Fever.  Happily, 
few  of  you  have  seen  either  a  case  of  ordinary  cholera  or  the  secondary 
fever,  which  was  not  so  common,  but  not  a  few  of  your  teachers  have 
seen  and  done  their  utmost  to  save  many  a  case.  In  most  epidemics 
the  disease  was  very  fatal  during  the  cold  stage,  and  where  very  much 
water  had  been  already  drained  off  from  the  blood  into  the  intestinal 
canal  the  patient  died  in  collapse.  In  some  of  the  cases  which  recov- 
ered the  secondary  fever  was  so  slight  that  it  attracted  little  or  no  atten- 
tion ;  but  occasionally  I  have  seen  it  very  marked  indeed,  and  have  lost 
patients  from  secondary  fever  who,  some  days  before,  had  passed  through 
severe  collapse  and  were  considered  to  be  recovering.  I  believe  that  this 
febrile  stage  of  cholera  corresponds  very  closely  to  the  prolonged  feverish 
condition  characteristic  of  typhus  or  typhoid,  for  example,  and  to  the  so- 
called  hot  or  febrile  stage  of  an  intermittent.  In  an  ordinary  cold  the 
feverish  state  usually  lasts  but  a  very  short  time,  perhaps  not  longer  than 
from  ten  to  twenty-four  hours.  In  typhoid  fever,  however,  it  may  last 
for  six  weeks  or  more,  and  in  acute  rheumatism  it  may  extend  over  two 
months.  During  the  whole  of  this  long  period  the  temperature  of  the 
patient's  blood  may  not  once,  even  for  a  single  hour,  fall  to  the  normal 
standard,  though  in  many  cases  it  falls  and  rises  several  times  in  the 
course  of  the  attack,  passing  three  or  four  degrees  above  the  normal, 
and  then  perhaps  going  down  to  that  point,  again  rising,  and  so  on. 
In  an  ordinary  cold  or  catarrh  the  chilly  stage  is  usually  followed,  in  the 
course  of  five  or  six  hours,  by  free  perspiration,  which  immediately  affords 
great  relief,  and  in  many  instances  seems  to  cure  the  patient  at  once. 

In  fevers  and  extensive  inflammations  the  nervous  system  generally 
is  affected.  In  some  forms  the  action  of  the  brain  is  very  much  dis- 
turbed. Soon  after  the  preliminary  phenomena  of  the  common  cold 
have  occurred,  the  pulse  increases  in  frequency,  and  there  is,  possibly, 
severe  headache,  the  whole  of  the  head,  perhaps,  feeling  full,  almost  to 


212  .  COLD   STAGE    OF  A  CUE- FIT. 

bursting,  as  if  it  had  been  forcibly  distended  with  more  than  it  could 
properly  contain.  The  action  of  the  mind  is  affected.  No  one  when 
he  is  attacked  can  perform  much  intellectual  work.  His  memory  suffers, 
and  to  think  at  all  is  a  painful  effort.  He  probably  feels  more  inclined 
to  lie  down  and  do  nothing.  If  he  goes  to  bed,  instead  of  falling  asleep 
he  tosses  about  from  one  side  to  the  other  in  an  uncomfortable  way ; 
perhaps  he  dreams  of  all  kinds  of  horrible  things,  and  wakes  up  sud- 
denly, finding  the  mouth,  fauces,  and  tongue  dry  and  uncomfortable. 
There  is  still  more  or  less  feeling  of  fulness  and  distention  about  the 
head.  The  patient  again  tries  to  go  to  sleep,  only  to  be  disturbed  by 
more  unpleasant  dreams  and  to  wake  again,  perhaps  frightened,  in  a 
short  time.  Oftentimes  there  is  chilliness,  or  a  creeping  sensation  is 
experienced  over  the  general  surface,  the  muscles  seem  fatigued,  and 
there  is  a  general  feeling  of  lassitude.  These  phenomena  indicate  a 
wide-spread  disturbance  of  the  nervous  system,  cerebral,  spinal,  and 
ganglionic,  caused  probably  by  the  action  upon  the  nerves  and  nerve- 
centres  of  certain  materials  which  ought  to  have  been  eliminated,  but 
which  have  unduly  accumulated  in  the  blood. 

Such  are  some  of  the  broad  phenomena  which  almost  every  one  has 
experienced  who  has  taken  a  bad  cold  or  has  suffered  from  any  form  of 
fever.  In  severe  and  specific  fevers  and  general  inflammations  all  these 
nerve  phenomena  are  more  strikingly  developed,  and  trouble  the  patient 
for  a  longer  period  of  time.  In  any  well-developed  fever,  for  instance, 
the  patients  may  pass  many  sleepless  nights.  They  may  be  troubled  with 
headache  for  a  fortnight  or  three  weeks,  or  even  longer,  and  may  be 
restless  and  wakeful  during  the  whole  of  the  time. 

The  chilly  sensation,  like  the  cold  stage  of  an  ague-fit,  is  succeeded, 
after  a  varying  period  of  time,  by  a  very  different  state  of  things.  The 
blood  returns  in  volumes  to  the  surface  of  the  body.  The  little  arteries 
dilate,  the  capillaries  are  distended,  the  color  returns  and  is  intensified, 
and  the  skin  becomes  hot  to  the  feel,  but  it  remains  dry.  There  is  often 
headache,  and  the  patient  will  perhaps  tell  you  that  his  head  feels  ready 
to  burst.  This  is  the  hot  stage,  which  is  soon  followed  by  the  last  or 
sweating  stage.  The  skin  is  bathed  with  perspiration,  which  continues 
it  may  be  for  several  hours,  so  that  the  cuticle  becomes  completely 
soddened  and  softened.  In  this  way  a  quantity  of  water  with  certain 
organic  matters  dissolved  in  it,  and  often  amounting  to  several  pounds 
in  weight,  is  very  quickly  removed  from  the  blood. 

The  action  of  the  skin  and  other  excreting  organs  of  the  body,  which 
had  been  partially  suspended  during  the  accession  of  the  attack,  and  in 
many  cases  for  some  days  before,  is  a  general  fact  of  great  importance, 
and  marks  the  temporary  abatement  or  actual  cessation  of  all  febrile  and 
inflammatory  disorders.  If  these  phenomena  can  be  caused  to  come  on 
somewhat  earlier  than  in  the  natural  course  of  events,  the  duration  of 
the  febrile  or  inflammatory  attack  is  to  that  extent  reduced.  As  soon 


FREE  SECRETION  IN  FEVER.  213 

as  the  sweating  comes  on  the  patient  may  feel  relieved,  but  until  it  has 
occurred  he  may  experience  much  discomfort.  Till  then  you  may  have 
felt  very  anxious  about  the  case.  We  are  unfortunately  unable  to  ascer- 
tain at  the  commencement  of  the  attack  how  bad  the  patient  is  likely  to 
be ;  we  never  know  to  what  extent  the  grave  symptoms  of  the  malady 
may  continue  to  increase,  or  for  how  long  a  time  the  patient  will  con- 
tinue to  get  worse.  Until  sweating  and  free  secretion  have  occurred  we 
can  seldom  judge  as  to  the  probability  of  recovery  or  the  duration  of 
the  time  of  illness. 

Of  Free  Secretion  which  Leads  to  Recovery. — Recovery  is  associated 
with  the  gradual  removal  from  the  organism  of  substances  which  prob- 
ably have  been  accumulating  for  some  time  in  the  blood  and  nutrient 
fluids.  These  substances  are  slowly  removed  by  the  agency  of  the  kid- 
neys, skin,  bowels,  and  other  emunctories.  When  the  skin  acts  pretty 
freely,  you  become  thirsty  and  imbibe  a  quantity  of  fluid,  which  is  again 
quickly  removed  by  the  kidneys.  The  bowels  act  freely,  although  per- 
haps for  some  time  before  the  illness  and  during  part  of  the  attack  they 
had  been  confined,  or  had  only  acted  imperfectly,  especially  when  febrile 
action  was  most  intense.  The  glands  of  the  mucous  membrane  of  the 
intestinal  canal,  like  other  glands,  do  not  act  as  freely  in  the  early  period 
of  a  cold  as  they  do  in  the  healthy  state.  When,  however,  the  patient 
returns  to  the  normal  condition  these  glands  act  freely,  and  the  tendency 
to  constipation  and  defective  action  passes  off. 

Moreover,  as  the  feverishness  abates  there  will  be  increased  action  of 
several  glands  as  compared  with  their  activity  in  the  ordinary  state  of 
health.  Not  only  do  the  kidneys  and  the  cutaneous  glands  act  in  an 
unusual  way  for  some  time  after  recovery,  but  the  glands  of  the  mucous 
membrane  of  the  nose  and  those  of  the  mucous  membrane  of  the  air- 
tubes  also  continue  to  secrete  freely  for  some  time.  Many  of  us  while 
in  perfect  health  might  leave  our  pocket-handkerchiefs  behind  without 
experiencing  inconvenience,  but  when  suffering  from  a  cold  it  is  well 
not  to  be  neglectful.  A  quantity  of  secretion  is  poured  out  from  the 
mucous  membrane  of  the  nose,  and  in  many  cases  also  from  that  of  the 
windpipe  and  bronchial  tubes. 

The  secretion  is  modified  mucus.  In  the  healthy  state  the  mucus 
which  is  formed  is  extremely  small  in  amount.  This  mucus  is  princi- 
pally produced  in  minute  glands  connected  with  the  mucous  membrane 
and  which  open  upon  its  free  surface.  The  same  glands,  when  the  fever 
of  an  ordinary  cold  is  passing  off,  secrete  an  undue  quantity  of  mucus. 
Exaggerated  action  proceeds  in  connection  with  all  the  mucous  surfaces, 
and  persists  for  a  certain  period  of  time,  varying  from  twelve  or  twenty- 
four  hours  to  many  days.  The  patient  then  usually  gets  better,  and 
everything  slowly  returns  to  its  normal  rate  of  action. 

Now  this  very  free  secretion,  in  certain  cases,  is  a  matter  of  serious 
importance.  There  are  certain  forms  of  inflammation  of  the  mucous 


214  TREATMENT  OF  A    COLD. 

membrane  of  the  air-tubes,  including  the  nasal  passages,  in  which  there 
may  be  an  undue  secretion  of  altered  mucus,  amounting  to  six  or  eight 
ounces  in  the  twenty-four  hours.  In  some  sad  cases,  happily  not  very 
common,  an  excessive  quantity  of  secretion  is  so  quickly  poured  out 
that  it  accumulates  in  the  smaller  air-tubes,  and  death  may  be  caused 
by  suffocation  in  the  course  of  a  few  hours. 

The  mucous  membrane  of  some  persons'  air-tubes  is  constantly  in  so 
sensitive  and  irritable  a  state,  that  whenever  the  weather  is  either  cold 
or  damp  they  suffer  more  or  less.  Such  patients  ought  to  spend  their 
winter  in  a  warmer  climate,  where  they  can  be  out  in  the  open  air  almost 
daily;  for  if  they  remain  in  London  they  generally  have  to  be  shut  up 
in  warm  rooms  for  a  great  part  of  the  winter,  a  course  very  detrimental 
to  the  general  health,  and  likely  to  render  the  mucous  membrane  still 
more  irritable  and  sensitive  to  adverse  atmospheric  changes  as  life  ad- 
vances. 

Coryza  is  the  scientific  name  for  a  cold  associated  with  the  secretion 
and  removal  of  a  considerable  quantity  of  fluid  secretion  and  viscid 
mucus  from  the  secreting  follicles  and  surface  of  that  part  of  the  mucous 
membrane  which  lines  the  nasal  passages  and  adjoining  cavities.  Catarrh, 
Gravedo,  are  also  terms  applied  to  a  cold  in  the  head.  The  word  Coryza, 
liopi^a,  is  supposed  to  be  derived  from  K.6po$  or  /capa,  the  head,  and  f««,  to 
boil.  I  am  not,  however,  sure  whether  this  derivation  is  perfectly  accu- 
rate. The  condition  was,  perhaps,  so  called  because  some  people,  suffer- 
ing from  a  very  bad  cold,  say  that  they  feel  as  if  the  blood  in  the  head 
was  in  a  boiling  state. 

Of  the  Principles  upon  which  the  Treatment  of  a  Cold  should  be 
Conducted. — As  regards  treatment,  I  suppose  many  would  say  "let  a 
cold  alone;  "  "it  will  get  well  of  itself;  "  "do  nothing."  I  am  quite 
ready  to  admit  that  an  ordinary  cold  will  get  well  without  any  active 
treatment.  Nevertheless,  a  bad  cold  is  a  very  unpleasant  affection  in 
many  ways,  and  it  is  desirable  to  mitigate  its  intensity  and  shorten  the 
attack,  if  we  can  do  so.  Besides,  as  I  shall  have  to  explain,  many 
serious  maladies  in  their  early  stage  may  be  easily  mistaken  for  an  ordi- 
nary cold,  and  in  many  cases  real,  advantage  does  result  from  the  early 
adoption  of  judicious  treatment.  We  will,  therefore,  endeavor  to  decide 
as  to  the  principles  according  to  which  the  treatment  of  a  cold  and  allied 
derangements  should  be  conducted. 

The  phenomena  characteristic  of  an  ordinary  cold,  as  I  have  just  re- 
marked, are  present  during  the  period  of  accession  of  many  forms  of 
fever,  and  sometimes  in  a  greatly  in-tensified  state.  You  ought,  there- 
fore, to  know  whether,  and  by  what  means,  these  symptoms  may  be 
modified,  or  the  changes  which  usher  in  convalescence  encouraged,  so 
that  the  latter  be  made  to  occur  somewhat  earlier  than  they  would  do  if 
the  malady  ran  its  ordinary  course.  Obviously,  the  thing  to  try  to  do  in 
the  treatment  of  maladies  of  the  class  we  are  considering  is  to  bring  on 


DIURETICS  AND  PURGATIVES.  21$ 

the  period  of  perspiration  as  early  as  possible  and  to  excite  the  action 
of  the  various  glands  of  the  body. 

The  blood  has  been  diverted  from  the  surface  to  the  internal  organs  of 
the  body,  and  we  want,  if  we  can,  to  determine  its  flow  towards  the  skin, 
in  order  that  much  of  its  water  and  some  of  its  organic  constituents  may 
be  removed  by  the  glands  and  discharged  in  the  form  of  perspiration. 
External  warmth  will  relieve  the  feeling  experienced  when  a  cold  is 
coming  on,  and  I  think  that  sometimes  the  malady,  and  possibly  some 
severe  acute  affections,  may  be  cut  short  in  this  way.  The  patient  is 
told  to  get  into  a  warm  bed  or  to  take  a  warm  bath.  But  the  applica- 
tion of  cold  externally  has  been  as  strongly  recommended  as  warmth, 
for  the  very  same  purpose  in  the  same  cases ;  and  you  might  be  led  to 
suppose  that  here,  as  in  some  other  instances,  opposite  and  conflicting 
practices  had  been  advised  and  adopted  for  the  relief  of  the  very  same 
malady.  But  this  is  not  really  so  ;  for  whether  you  wrap  a  patient  in  a 
sheet  dipped  in  warm  water  or  in  cold  water,  it  makes  very  little  differ- 
ence, except  that  a  cold  sheet  is  somewhat  more  disagreeable  to  the 
patient  than  a  warm  one.  Cold,  wet  packing  will  bring  about  just  the 
same  action  as  warm  packing  or  a  warm  bath.  For  the  chilly  feeling 
produced  by  the  first  contact  of  the  cold  wet  sheet  is  soon  followed  by 
reaction,  and  is  replaced  by  a  gentle  glow,  succeeded  by  free  perspiration. 

Diuretics. — But  besides  trying  to  excite  perspiration,  you  may  endeavor 
to  cause  various  eliminating  organs  to  act  freely.  You  should  give  unir- 
ritating  diuretic  remedies,  such  as  Liquor  Ammonia  Acetatis,  Citrate  of 
Ammonia,  Citrate  of  Potash,  Nitrate  of  Potash,  and  Chlorate  of  Potash. 
These  all  act,  more  or  less,  upon  the  kidneys,  and  increase  the  flow  of 
urine ;  some  of  them  act  upon  the  skin,  and  in  other  ways  promote  the 
removal  from  the  blood  of  noxious  substances  which  have  accumulated 
in  it.  They  and  many  other  remedies  are  thus  of  use  in  the  treatment 
of  an  ordinary  cold  and  allied  ailments.  I  often  suggest  the  following 
prescription  : — Spirit  of  Mindererus  {Liquor  Ammonite  Acetatis),  two 
ounces ;  Spirit  of  Chloroform  (Spiritus  Chloroformi"),  from  one  to  two 
drachms ;  Nitrate  of  Potash  (Potassce  Nitras\  sixty  grains  ;  or  Chlorate 
of  Potash  {Potasses  Chloras),  from  one  to  two  hundred  grains ;  Syrup 
of  Orange,  of  Squill,  or  of  Tolu,  half  an  ounce,  and  water  to  six  ounces. 
The  dose  is  half  an  ounce,  or  a  tablespoonful,  with  as  much  water,  once 
in  two  hours,  or  less  frequently,  for  three  or  four  days. 

Purgatives. — And,  lastly,  the  elimination  of  noxious  matters  which 
have  accumulated  in  the  blood  may  be  further  promoted  by  exciting  to 
a  moderate  extent  the  action  of  the  intestinal  canal.  In  a  cold  the 
bowels  are  generally  more  or  less  confined,  and  in  many  cases  there  has 
been  but  imperfect  action,  perhaps,  for  some  time  previous  to  the  attack. 
I  therefore  recommend  you  to  make  full  inquiry  upon  this  point,  and, 
if  necessary,  order  for  the  patient  some  mild  laxative  that  will  act  upon 
the  bowels  and  favor  excretion.  Thus  you  may,  perhaps,  shorten  by  a 


2l6  ONLY  !4    COLD. 

day  or  two  the  period  of  the  duration  of  the  cold.  In  the  highly  fever- 
ish condition  which  often  comes  on  soon  after  a  surgical  operation,  re- 
lief may  be  afforded  in  the  course  of  a  few  hours  by  the  administration 
of  purgatives,  sudorifics,  and  diuretics.  One  or  two  grains  of  Calomel 
will  be  found  to  act  admirably  in  many  of  the  most  serious  of  these 
cases.  The  temperature  falls  soon  after  the  dose  has  been  taken,  and 
the  patient  often  experiences  great  relief  long  before  the  medicine  be- 
gins to  act  on  the  bowels. 

The  fact  of  improvement  so  immediately  following  the  use  of  reme- 
dies which  increase  the  action  of  the  skin,  kidneys,  and  bowels,  favors 
the  conclusion  that  the  fever  is  due  to  the  accumulation  of  certain  mate- 
rials in  the  blood,  the  elimination  of  which  is  followed  by  relief,  and, 
as  we  say,  the  resolution  of  the  fever.  It  is  important  to  consider  these 
matters,  the  more  so  just  now,  because  there  is  too  great  a  tendency  to 
altogether  discard  the  use  of  many  medicines  which  are  of  great  value  in 
the  treatment  of  disease. 

Of  the  Recognition  and  Management  of  Affections  which  Begin  like 
an  Ordinary  Cold. — Some  cases  which  at  the  outset  seem  to  be  nothing 
more  than  an  ordinary  cold  or  catarrh,  do  not  prove  to  be  of  this  na- 
ture, but  issue  in  some  form  of  serious  acute  disease.  Those  terrible 
fevers  which  occur  in  all  the  large  cities  of  Europe,  and  which  carry 
off  so  many  thousands  every  year,  may  come  on  just  as  an  ordinary 
cold  does.  During  the  period  of  accession  the  symptoms  are  much  the 
same,  and  both  the  patient  and  his  doctor  may  for  some  days  think 
there  is  not  much  the  matter.  The  patient  feels  so  strongly  convinced 
that  he  is  suffering  only  from  an  ordinary  cold  that  he  goes  about  just 
as  usual.  When,  however,  he  gets  worse  from  day  to  day  and  feels 
decidedly  weaker,  he  begins  to  be  alarmed.  At  length  he  is  obliged  to 
take  to  his  bed,  his  temperature  is  found  to  be  and  to  remain  above  the 
normal,  perhaps  rising  to  102°  and  103°.  By  this  time  the  practitioner 
is  able  to  determine  the  nature  of  the  case.  Instead  of  the  attack  being, 
as  the  patient  himself  supposed,  an  ordinary  cold,  it  turns  out  to  be  a 
specific  fever,  of  a  kind  which  not  un frequently  destroys  life.  It  may 
be  that  under  the  most  favorable  circumstances,  and  with  the  best  nurs- 
ing and  medical  treatment,  the  rate  of  mortality  will  not  be  less  than 
one  out  of  every  seven  or  eight  attacked  by  the  disease.  It  is  a  fact  that 
many  serious  attacks  of  fever  begin  just  like  an  ordinary  cold.  Now 
if  you  happen  to  be  called  in  just  when  the  fever  is  coming  on,  and 
you  thoughtlessly  remarkt  that  "  this  is  only  an  ordinary  cold  ;  I  need  not 
do  anything,"  think  of  the  dilemma  in  which  you  may  be  placed.  When 
the  severe  nature  of  the  disease  becomes  apparent,  you  will  be,  as  it  were, 
convicted  of  having  made  a  very  serious  mistake.  Very  likely  neither 
the  patient  nor  his  friends  will  have  any  further  confidence  in  you,  and 
you  may  be  pronounced  to  be  an  ignorant  person,  who  knows  very  little 
about  his  profession.  You  may  in  consequence  get  out  of  heart  and  feel 


IMPORTANCE    OF  TREATMENT.  2 1/ 

altogether  dissatisfied  with  yourself.  As  a  fact,  it  may  have  been  impos- 
sible for  anyone  to  make  a  diagnosis  at  a  very  early  period  of  the  attack; 
but  the  right  course  would  have  been  to  have  waited  until  the  premoni- 
tory symptoms  passed  off,  or  until  some  definite  characteristics  of  a 
special  malady  had  manifested  themselves.  You  should  always  carefully 
inquire  into  all  the  facts  of  any  given  case,  listen  attentively  to  what  the 
patient  has  to  say  concerning  the  symptoms  which  disturb  him,  and  do 
all  you  can  to  relieve  them,  postponing  any  decided  expression  of  opinion 
as  to  the  precise  nature  of  the  disease  until  your  next  visit,  when  you 
may  perhaps  be  able  to  speak  with  decision. 

Even  if  the  disease  should  be  only  a  common  cold,  you  will,  never- 
theless, find  in  practice  that  many  persons  who  experience  suffering,  dis- 
comfort, or  even  mere  inconvenience,  strongly  desire  to  be  relieved  of 
their  troubles,  and  as  quickly  as  possible.  Of  the  sick  who  send  for  you, 
a  considerable  proportion  will  certainly  expect  that  you  will  do  something 
for  them.  Though  if  you  were  in  the  same  condition  yourself  you  might 
be  inclined  to  leave  the  case  to  nature  and  not  take  any  medicine  nor 
desire  to  follow  any  course  more  unusual  than  indulging  in  a  little  more 
rest  than  when  in  good  health,  your  patient  will  expect  you  to  prescribe 
something  that  will  relieve  him  or  help  him  to  get  well.  And  unques- 
tionably you  may  help  persons  suffering  from  a  severe  cold  if  you  give 
sudorifics,  diuretics,  and  a  gentle  purgative. 

Especially  in  the  case  of  children  is  it  necessary  to  be  very  cautious 
in  committing  yourself  to  a  positive  opinion  at  an  early  period  of  a 
febrile  attack.  You  may  mistake  a  serious  case  for  a  slight  one,  or  the 
reverse.  You  will  be  astonished  at  the  very  serious  aspect  sometimes 
presented  by  many  a  case  of  mere  stomach  disturbance.  A  child  who 
has  partaken  of  unripe  fruit  may  be  very  ill  indeed  a  few  hours  after- 
wards, with  a  temperature  of  104°,  flushed  face,  quick  pulse  and  respira- 
tion, with  a  suffering,  anxious  look.  An  inexperienced  practitioner  would 
perhaps  tell  the  friends  that  some  severe  fever  or  other  acute  disease  was 
certainly  about  to  establish  itself,  when,  perhaps,  a  few  hours  afterwards 
the  bowels  act,  the  temperature  falls  to  the  normal,  and  when  he  next 
visits  his  patient  he  finds  him  well,  and  the  friends  laughing  about  his 
gloomy  prognostications. 

In  children  suffering  from  slight  ailments,  I  have  observed  the  temper- 
ature rise  from  the  normal  to  104°,  or  even  higher,  and  descend  to  the 
normal,  within  twenty-four  hours,  so  rapidly  may  considerable  changes 
in  the  temperature  of  the  blood  of  children  occur.  Such  cases,  I  need 
scarcely  say,  require  simple  treatment.  A  purgative  dose  of  castor-oil 
is  sometimes  needed,  and  the  patient  is  well  again  as  soon  as  it  operates. 
The  child,  as  often  happens,  is  very  thirsty,  and  you  may  allow  it  to 
drink  water.  Plenty  of  toast  and  -water  may  be  given,  or  plain  water, 
if  the  patient  likes  it  better,  provided  it  has  been  well  boiled.  Water  or 
milk  and  water  will  help  the  skin  and  kidneys  and  bowels  to  act  freely, 
19 


2l8  IMPORTANCE   OF  TREATMENT. 

and  in  consequence  the  feverishness  will  subside  and  the  patient  regain 
the  usual  state  of  health.  Sometimes,  however,  a  feverish  attack  instead 
of  subsiding  continues  for  several  days.  The  child  may  be  ill  for  a.  week 
or  two,  and  require  careful  management,  although  no  definite  fever  is  de- 
veloped. Neither  scarlet  fever,  nor  typhus  fever,  nor  any  other  specific 
disease  may  be  manifested  ;  but  a  general  feverish  state  may  be  estab- 
lished, and  may  continue  for  several  days,  and  then  gradually  subside, 
leaving  the  patient  thin  and  weak  and  out  of  health. 

It  must  be  admitted  that  in  former  days  many  doctors  gave  too  much 
physic  and  were  somewhat  too  fussy.  In  these  days,  however,  I  fear 
there  is  a  tendency,  or  more  than  a  tendency,  to  err  in  an  opposite  di- 
rection. Some  practitioners,  having  convinced  themselves,  seem  to  be 
most  anxious  to  convince  the  public  and 'the  profession  that  the  chief 
duty  of  a  medical  adviser  is  to  study,  note,  and  carefully  watch  the 
progress  of  a  malady — to  observe,  if  he  is  qualified  to  do  so,  the  minute 
changes  taking  place  in  the  tissues  of  the  sick  man,  in  order  that  he  may 
discover  facts  which  will  increase  our  knowledge  of  the  nature  of  the 
pathological  processes,  and  possibly  lead  to  the  enunciation  of  new  prin- 
ciples of  treatment  for  the  benefit  of  sufferers  in  the  next  and  succeeding 
generations.  But  this  view  of  medical  aspiration  is  not  always  appreci- 
ated by  the  patient,  especially  if  the  doctor's  visits  are  not  purely  of  an 
honorary  character,  and  even  then  it  will  be  found  that  there  are  some 
few  patients  so  peculiar  in  their  notions  as  to  object  to  their  bodies  being 
used  for  observation,  or  their  sufferings  studied  and  noted  as  interesting 
pathological  phenomena,  which  may  be  further  elucidated  as  the  case 
proceeds.  You  must  really  bear  in  mind  that  patients  want  to  be  relieved 
as  well  as  watched,  and  unless  you  can  be  of  some  use  to  them — unless 
you  can  advise  and  help  them,  they  may  regard  you  as  a  nuisance,  in- 
stead of  discovering  in  you  a  consolation.  But,  further,  we  really  ought 
to  do  all  we  can  not  only  to  remove  bodily  aches  and  pains,  but  also  to 
relieve  our  patients'  minds.  You  will  not  reduce  the  mental  anxiety  of 
a  sick  man  if  you  tell  him  you  can  do  nothing  to  relieve  his  pain,  noth- 
ing to  expedite  his  recovery,  nothing  to  avert  impending  morbid  change 
or  to  mitigate  the  severity  of  the  disease.  I  find  that  some  doctors,  if 
they  get  ill,  even  though  the  illness  is  obviously  not  a  serious  one,  be- 
come very  anxious,  and  of  all  sick  people  they  are  oftentimes  the  most 
difficult  to  manage.  They  usually  think  themselves  worse  than  they  are, 
and  are  almost  invariably  desirous  that  something  practical  should  be 
done.  I  have  sometimes  ventured  to  discuss  with  a  medical  friend  the 
actual  nature  and  import  of  the  symptoms  from  which  he  was  suffering, 
but  I  generally  find  that  my  friend  is  sadly  disappointed  if  I  do  not  pro- 
pose to  "do  something"  for  him  or  suggest  some  operation  to  relieve 
him.  If  I  suggest  to  a  medical  patient  that  the  malady  will  probably 
get  well  of  itself,  he  will,  perhaps,  feel  disappointed,  if  not  hurt ;  but  if  I 
propose  that  he  should  take  a  few  doses  of  the  Liquor  Ammoniae  Acetatis, 


CHANGES  IN  TISSUES  IN  FEVER  AND  INFLAMMATION.     21$ 

Nitrate  or  Chlorate  of  Potash,  and  Sal  Volatile,  a  practitioner  of  even  a 
philosophical  turn  of  mind  will  feel  quite  happy,  and  will  take  the  med- 
icine ordered  with  regularity,  and  bear  his  ailments  with  cheerfulness. 

I  advise  you  to  bear  in  mind  the  principle  upon  which  the  treatment 
of  a  cold  or  an  ordinary  febrile  attack  is  to  be  conducted,  and  I  recom- 
mend you  to  be  careful  not  to  commit  yourselves  too  hastily  to  a  positive 
opinion  as  to  the  exact  nature  of  a  febrile  attack  which  has  only  lately 
come  on.  It  is  important , not  to  make  too  light  of  it,  on  the  one  hand, 
or  on  the  other  to  cause  needless  alarm  by  suggesting  to  anxious  friends 
that  what  is  probably  only  a  most  trifling  and  unimportant  temporary 
derangement  may  turn  out  to  be  a  grave  disorder. 

OF  THE  ACTUAL  CHANGES  IN  THE  AFFECTED  TISSUES  IN  FEVER 
AND  INFLAMMATION. 

I  now  desire  to  consider  more  particularly  the  actual  phenomena  of 
Fevers  and  Inflammations,  and  the  general  nature  of  the  minute  changes 
upon  which  they  depend. 

I  have  said  before  that  in  all  fevers  and  inflammations  there  is  an 
elevation  of  temperature.  Whether  the  rise  begins  in  the  blood  or  in 
the  tissues  outside  the  capillaries,  is  a  question  concerning  which  some 
difference  of  opinion  may  be  entertained.  In  some  cases  it  is  certain 
that  the  tissue  elements  exhibit  the  earliest  departure  from  the  normal 
state,  and  in  all  probability  it  is  there  that  the  rise  in  temperature  begins. 
But  the  blood  is  soon  affected,  for  in  all  cases  the  blood  in  the  adjacent 
capillaries  becomes  hotter,  and  it  is  by  the  movements  of  the  blood  that 
the  distribution  of  heat  is  effected.  On  the  other  hand  there  is  no  doubt 
that  some  fevers  and  inflammations  begin,  so  to  say,  in  the  blood. 

In  every  form  of  marked  inflammation  and  fever  the  vessels  of  the 
affected  part  contain  more  blood  than  they  do  in  the  normal  state.  Par- 
ticularly the  capillary  vessels  and  the  small  veins  are  distended.  If  you 
watch  the  phenomena  of  local  inflammation  in  one  of  the  lower  animals, 
as  for  example  that  form  which  may  be  excited  in  the  web  of  the  frog's 
foot  by  the  application  to  one  spot  of  a  small  portion  of  mustard  for  a 
few  minutes,  and  carefully  observe  the  alteration  in  the  circulation  there- 
by induced,  you  will  gain  much  important  information  concerning  the 
nature  of  the  process.  You  will  notice  in  the  first  place  that  the  vessels 
have  become  much  dilated,  while  the  movement  of  the  blood  along  them 
gets  slower  and  slower.  At  last  the  circulation  completely  stops.  If  at 
this  stage  of  pathological  change  the  mustard  be  removed  and  the  web 
be  kept  perfectly  moist,  it  will  be  found  that  the  movement  of  the  blood 
will  begin  again,  and  that  much  of  it  will  find  its  way  on  to  the  small 
veins.  In  fact  the  disturbance  will  soon  cease.  The  normal  state  of 
the  circulation  will  be  restored,  and  without  any  damage  whatever  to 
vessels,  nerves,  or  other  tissues  having  taken  place. 

In  fever  there  can  be  no  doubt  that  the  same  sort  of  change  occurs  in 


220     CHANGES  IN  TISSUES  IN  FEVER  AND  INFLAMMATION. 

fhe  capillaries,  but  the  degree  of  change  is  so  slight  that  it  is  not  in  all 
cases  to  be  demonstrated.  You  may  look  upon  a  cold  as  a  slight  fever, 
while  a  chilblain  may  be  adduced  as  an  example  of  a  slight  inflammation. 

Some  authorities  consider  that  febrile  disorders  should  be  classed 
among  nerve  disorders,  and  the  arguments  advanced  in  favor  of  this 
view  also  apply  to  the  case  of  inflammations.  But  would  it  not  be  un- 
reasonable to  include  flea-bites,  and  boils,  and  abscesses  in  the  class  of 
nervous  diseases?  In  point  of  fact,  nerves  and  nerve-centres  are  invari- 
ably affected  in  all  fevers  and  inflammations,  however  slight.  Indeed, 
no  changes  whatever  which  involve  alterations  in  the  diameter  of  the 
small  arteries  can  take  place  in  the  body  without  nerves  being  concerned, 
and  the  essential  phenomena  both  of  fever  and  inflammation  are  inti- 
mately connected  with  disturbed  arterial  and  capillary  action.  Still  these 
conditions  cannot  properly  be  regarded  as  nerve  diseases.  The  patho- 
logical action  does  not  begin  in  nerve  structures,  and  the  nerves  and 
nerve-centres,  so  far  from  being  the  points  of  departure  of  the  morbid 
change,  are  only  affected  in  consequence  of  preliminary  changes  in  other 
textures. 

The  phenomena  of  some  fevers  and  general  inflammations  are  due  to 
changes  which  have  taken  place  in  the  blood,  and  there  is,  as  I  have  re- 
marked, undoubted  evidence  of  the  blood  being,  as  it  were,  the  starting- 
point  of  all  the  phenomena.  The  disease  begins  in  the  blood.  A  poison, 
or  materies  morbi,  may  infect  the  blood  in  the  first  instance,  and  through 
the  blood  various  tissues  and  organs  may  suffer.  It  is  very  probable,  I 
think,  that  the  afferent  nerve-fibres  distributed  to  the  capillary  vessels 
are  disturbed  either  by  the  action  upon  them  of  the  altered  fluid  which 
transudes  through  the  vascular  walls,  or,  in  certain  cases,  by  the  growth 
and  multiplication  around  them  of  minute  particles  of  morbid  bioplasm 
(disease  germs)  which  also  traverse  the  thin  walls  of  the  capillaries,  thus 
leaving  the  blood  in  countless  numbers  and  passing  into  the  interstices 
of  the  surrounding  textures.  In  Scarlet  Fever  (Scarlatina]  the  "rash" 
depends  upon  the  capillaries  of  the  surface  of  the  skin  being  dilated  to 
such  an  extent  that  the  redness  of  the  affected  parts  is  as  intense  as  that 
of  the  skin  of  the  lips  in  the  ordinary  state.  The  bright  red  color  of 
the  skin  of  the  lips  is  due,  as  you  are  probably  aware,  to  the  number 
and  considerable  diameter  of  the  capillaries  of  the  skin  of  the  part,  and 
to  the  circumstance  that  these  vessels  are  covered  by  a  thin  layer  of 
epithelium  only.  In  scarlet  fever  the  redness  is  due  to  a  dilatation  of 
the  vessels,  somewhat  like  that  which  occurs  in  those  of  the  skin  of  the 
cheek  when  we  blush.  In  the  fever,  however,  the  blush  lasts  for  a  much 
longer  time.  The  period  of  vascular  congestion  of  the  cutaneous  capil- 
laries is,  in  most  febrile  diseases,  fixed  and  definite;  but  it  varies  con- 
siderably in  duration,  as  well  as  in  the  course  which  it  takes  in  different 
kinds  of  fever.  In  eruptive  fevers,  then,  and  in  some  general  inflam- 
mations, the  "  eruption  "  or  "  rash  "  results  from  dilatation  of  the  capil- 


THE  ACTION  OF  EXTERNAL    COLD   UPON  THE  BLOOD.     221 

lary  vessels,  which  lasts  for  a  certain  time.  The  mechanism  instrumental 
in  bringing  about  the  result  and  the  precise  changes  taking  place  in  the 
vessels  are  considered  on  page  231.  I  do  not  say  that  the  redness  of 
the  skin  is  due  to  increased  supply  of  blood,  for  probably  a  less  propor- 
tion of  blood  goes  to  the  part  than  in  the  normal  state.  In  a  given  time 
less  blood  passes  along  the  vessels,  but  they  are  distended,  and  more 
blood  remains  in  them;  their  walls  being  stretched  are  much  .thinner 
and  more  permeable  than  in  the  normal  state.  The  blood  is  not  actu- 
ally stagnant,  but  it  circulates  very  slowly. 

Slight  exposure  of  a  part  of  the  body  to  cold  may  cause  a  severe 
febrile  attack.  In  considering  how  cold  operates,  I  think  we  shall  find 
the  following  explanation  in  accordance  with  the  broad  facts  of  the  case  : 
The  heart's  action  being  at  the  time  feeble,  blood  will  be  flowing  but 
slowly  through  the  capillaries  of  the  skin.  The  blood  will,  therefore, 
for  a  much  longer  time  than  usual,  be  exposed  to  the  detrimental  influ- 
ence of  cold.  No  wonder  that  under  such  circumstances  chemical 
changes  of  an  unusual  kind  are  induced.  Substances  are  formed  which 
injuriously  affect  the  tissues  and  interfere  with  the  proper  performance 
of  many  of  the  normal  phenomena  of  secretion  and  nutrition.  The 
noxious  materials  dissolved  in  the  fluid,  transuding  with  it  through  the 
walls  of  the  capillaries,  would  come  in  contact  with  the  delicate  nerve- 
fibres  and  mar  their  action.  As  long  as  such  matters  remain  in  the 
blood  there  must  be  in  many  ways  a  departure  from  the  healthy  state ; 
but  as  soon  as  these  compounds  have  been  eliminated,  the  organism  will 
be  restored  to  its  normal  condition.  For  these  reasons  the  free  action 
of  organs  concerned  in  excretion  is,  as  I  have  already  stated,  of  the 
first  importance,  and  is  associated  with  the  subsidence  of  the  fever  and 
the  discomfort  which  accompanies  the  attack. 

There  are  several  affections  which  may  be  correctly  termed  either 
fevers  or  inflammations.  If  in  many  cases  you  looked  at  the  local  phe- 
nomena only,  you  would  use  the  term  inflammation,  while  to  the  general 
symptoms  consequent  upon  the  local  change  and  varying  with  it  in  in- 
tensity, you  would  apply  the  term  fever.  Not  only  is  inflammation  the 
cause  of  fever,  but  fever  in  many  cases  leads  to  inflammation.  In  truth, 
there  is  no  inflammation  without  a  degree  of  fever,  and  there  is  no  fever 
in  which  the  phenomena  essential  to  inflammation  are  entirely  absent. 
That  which  is  common  to  both,  to  all  fevers  and  to  all  inflammations, 
is  the  increased  growth  of  bioplasm,  consequent  upon  increased  facilities 
of  access,  or  of  the  greater  abundance  or  greater  permeating  property 
of  the  nutrient  fluid.  This  increased  growth  of  the  living  matter  is  in- 
variably associated  with  a  rise  in  the  temperature  of  the  tissue  or  organ 
in  which  it  takes  place,  above  the  normal  standard.  Erysipelas  may  be 
fairly  called  an  inflammation,  though  in  many  respects  it  exhibits  all  the 
characteristics  of  a  fever.  In  the  slightest  local  inflammation,  however 
limited  its  area 'may  be,  a  flea-bite  for  example,  the  phenomena  are  essen- 
19  * 


222  THE  MINUTE   CHANGES 

tially  the  same  as  in  a  fever,  only  they  are  circumscribed  to  a  partic- 
ular spot.  If  you  consider  the  actual  changes  which  occur  in  both  path- 
ological states,  you  will  find  that  they  approach  so  nearly  in  their  essen- 
tial features  as  to  justify  me  in  advancing  the  generalization  that  Inflam- 
mation is  a  local  fever  and  Fever  is  a  general  inflammation. 

If  we  consider  the  actual  phenomena  of  fever  and  inflammation,  as 
they  are  revealed  by  careful  microscopical  examination  of  complex 
tissues  involved,  we  shall  find  that  we  have  : — i.  Temporary  enlargement 
or  dilatation  of  the  capillary  vessels,  which  soon  become  filled  with  blood. 
2.  If  this  state  of  the  vessels  lasts  for  a  time,  exudation  of  fluid  occurs  and 
minute  particles  of  bioplasm  pass  through  the  capillary  walls,  and  grow 
and  multiply  in  the  new  situation.  3.  The  bioplasts  of  the  vessels,  nerve- 
fibres,  and  other  tissues,  being  supplied  with  more  nutrient  matter  than  in 
the  ordinary  state,  grow  larger  and  tend  to  divide  and  subdivide. 

The  particles  of  bioplasm,  or  living  matter,  in  all  the  tissues  and  fluids 
affected  are  invariably  enlarged  in  all  fevers  and  inflammations.  1  be- 
lieve it  to  be  impossible  for  fever  or  inflammation  to  occur  without  this 
enlargement  of  the  bioplasts  or  particles  of  living  matter,  without  the 
temporary  increase  of  the  living  matter  of  the  part  of  the  body  affected. 
The  living  particles  always  experience  increased  nutrition  under  the  con- 
ditions present  when  fever  or  inflammation  exists,  and  this  phenomenon, 
this  increase  of  the  bioplasm,  is  invariably  associated  with  a  rise  in  the 
temperature  of  the  part.  Rise  in  body-heat  in  fever  and  inflammation 
is  constant,  and  I  must  ask  you  to  note  the  important  fact  that  it  is  asso- 
ciated with  slow  and  impeded  capillary  circulation,  with  the  exudation  of 
fluid  and  minute  particles  of  living  matter  from  the  blood,  and  with  the 
increased  nutrition  and  growth  of  bioplasm.  So  far  from  depending 
upon  increased  oxidation,  inflammation  and  fever  often  coincide  with 
impaired  respiratory  function,  and  the  introduction  into  the  blood  of 
far  less  oxygen  than  in  health,  and  with  the  formation  and  removal  of 
less  than  the  ordinary  proportion  of  carbonic  acid. 

Slight  fevers  and  inflammations  do  not  necessarily  result  in  permanent 
tissue  changes.  Many  leave  no  traces  behind  them.  There  may  be  no 
degeneration  of  any  tissue  in  the  body,  no  structural  change,  no  evidence 
left  of  the  attack.  After  a  fever  or  inflammation  the  organism  may  be 
left  precisely  as  it  was  before  the  attack  occurred.  Nay,  one  or  more 
attacks  of  feverishness  during  early  life  seem  to  be  the  rule.  Almost 
every  child  suffers.  Indeed,  amongst  young  vertebrate  animals,  dogs 
for  instance,  attacks  of  feverishness  occur  in  almost  every  individual,  and 
the  disease  is  often  fatal.  In  many  cases,  however,  the  feverishness  after 
a  few  days  passes  off,  leaving  no  structural  change  or  damage. 

Of  a  Flea-bite. — If  we  thoroughly  understood  the  phenomena  which 
result  from  the  "bite"  of  a  common  flea,  we  should  know  very  much 
more  about  the  exact  nature  of  the  changes  which  occur  in  such  serious 
inflammations  as  erysipelas  than  we  do  at  present.  Possibly,  also,  such 


OCCURRING  IN  PUS-FORMATION-.  22$ 

information  might  enable  us  to  suggest  means  by  which  an  attack  might 
be  prevented,  or  at  least  the  inflammation  kept  from  spreading  until  a 
considerable  extent  of  the  surface  of  the  body  was  involved  in  the  dis- 
ease. 

You  may  remember  that  in  one  of  my  early  lectures  I  described  how, 
by  the  minute  but  exquisitely  sharp  lancet  of  an  insect,  the  formed  ma- 
terial of  a  cell  of  cuticle  might  be  easily  injured,  and  in  such  a  manner 
that  a  part  of  the  bioplasm  in  its  interior  would  be  exposed  to  the  con- 
tact of  the  fluid  which  moistens  the  tissue.  I  showed  that,  under  the 
circumstances,  the  access  of  the  surrounding  nutrient  material  to  the 
bioplasm  in  the  interior  of  the  cell  must  be  greatly  facilitated.  It  is 
obvious  that  much  more  nutrient  matter  would  reach  the  bioplasm  in  a 
given  time  when  the  so-called  cell-wall  was  thus  damaged  than  when  it 
was  intact.  In  the  normal  condition  of  the  cell,  every  particle  of  nutrient 
fluid  must  slowly  permeate  the  thick  layer  of  formed  material  which  con- 
stitutes the  outer  part  of  the  cell,  the  so-called  cell-wall,  before  it  can  reach 
the  bioplasm  and  be  assimilated  by  it.  When  the  formed  material  has 
been  torn,  nutrient  fluid  will  pass  at  once  to  the  bioplasm  and  come  into 
immediate  contact  with  it.  As  the  ordinary  formed  material  or  "cell- 
wall"  consists  of  several  layers  of  firm  cuticular  matter,  not  very  per- 
meable, the  ordinary  passage  of  soluble  nutrient  substances  through  it 
must  necessarily  be  a  slow  process.  But  when  the  formed  material  is 
injured  so  that  the  bioplasm  is  exposed,  the  access  is  free  and  the  pab- 
ulum is  at  once  appropriated.  The  result  is  the  rapid  increase  of  the 
bioplasm  or  living  matter.  Outgrowths  or  diverticula  soon  make  their 
appearance  at  different  parts  of  the  circumference  of  the  mass.  Some 
of  these  are  from  time  to  time  detached,  and  being  freely  supplied  with 
pabulum  they  grow,  and  multitudes  of  separate  masses  of  bioplasm 
quickly  result.  These  &r&  pus-corpuscles,  many  of  which  may  in  this  way 
be  formed  from  the  bioplasm  of  an  epithelium  cell  in  a  short  time. 

Pus  may  result  in  the  course  of  a  few  hours  by  the  growth  and  sub- 
division of  any  form  of  bioplasm,  if  it  be  supplied  with  an  unusual  amount 
of  pabulum.  The  appropriate  pabulum  coming  into  contact  with  the 
bioplasm,  the  latter  must  take  it  up  and  grow.  If  the  excess  of  pabulum 
were  not  taken  up  by  the  bioplasm  and  converted  into  the  quickly  growing 
living  matter,  pus,  it  would  become  decomposed,  and  the  products  result- 
ing from  decomposition  would  infallibly  cause  the  death  of  every  particle 
of  bioplasm  in  the  neighborhood.  "  Mortification  "  of  a  portion  of  the 
affected  tissue  would  result.  The  bioplasm  of  any  tissue,  thea,  as  well 
as  that  of  which  white  blood-corpuscles  and  lymph-corpuscles  are  com- 
posed, may  give  rise  to  a  form  of  bioplasm,  pus,  a  kind  of  living  matter 
having  general  powers  and  properties,  irrespective  of  the  particular  form 
of  normal  bioplasm  from  which  the  "pus"  may  have  been  derived.  The 
formation  of  pus  from  the  bioplasm  of  an  epithelial  cell  may  be  studied 
in  the  epithelium  of  the  skin,  as  well  as  in  that  of  the  air-tubes,  the 


224  THE  MINUTE   CHANGES 

bladder,  and  other  mucous  surfaces.  If  living  pus  be  examined,  active 
vital  movements  will  be  observed  in  almost  every  corpuscle ;  and  I  beg 
you  to  study  these  wonderful  movements  for  yourselves  and  ponder  over 
them,  for  they  are  worthy  of  your  thoughts.  See  p.  248;  also  "  Disease 
Germs"  or  "The  Microscope  in  Medicine,"  4th  edition.  . 

We  are  just  now,  however,  chiefly  concerned  with  the  changes  which 
occur  in  the  skin  beneath  the  epithelial  layer  in  an  ordinary  flea-bite. 
These  involve  the  vessels  and  nerve-fibres,  and  are  of  the  highest  interest. 
The  lancet  of  the  flea,  I  need  scarcely  tell  you,  goes  deeper  than  the 
deepest  layer  of  the  cuticle,  for  it  penetrates  the  vessels  and  occasions 
changes  in  the  capillaries  as  well  as  in  other  tissues  of  the  skin.  This  is 
of  importance,  inasmuch  as  an  excelle'nt  illustration  of  the  remarkable 
phenomena  which  occur  in  inflammation  of  a  complex  tissue  is  afforded. 
Here  we  have  a  comparatively  circumscribed  inflammation  admirably 
adapted  for  the  investigation  of  the  actual  phenomena  which  constitute 
the  inflammatory  process  as  it  occurs  in  a  compound  tissue,  like  the  true 
skin.  In  consequence  of  the  wound  inflicted  upon  the  capillary  vessels, 
there  is  of  course  slight  escape  of  blood  into  the  adjacent  tissues.  This 
haemorrhage  gives  rise  to  a  very  small  deep  red  punctum  or  spot,  which 
does  not  disappear  on  pressure,  called  zfetechia  (from  the  Italian  Pete- 
chio,  a  flea-bite).  The  important  fact  to  which  I  now  wish  to  direct  your 
attention  is  not  the  petechia  caused  by  the  escape  of  a  minute  quantity 
of  blood,  but  the  less  intensely  red  area  around  it,  which  does  disappear 
when  the  finger  is  pressed  upon  it,  so  that  the  blood  may  be  for  a  moment 
driven  out  of  the  distended  capillaries.  'A  short  time  after  the  lancet  of 
the  flea  has  penetrated  the  cuticle  and  subjacent  tissues,  there  appears  this 
bright  red  blush  around  the  point  which  indicates  the  position  of  the 
wound.  The  area  forming  the  round  red  spot,  with  the  appearance  of 
which  most  of  us  are  familiar,  is,  I  suppose,  of  the  same  diameter  in  all 
cases  where  the  lancet  of  the  flea  is  of  the  same  size,  the  wound  of  the 
same  depth,  and  the  irritating  poison  discharged  the  same  in  amount. 

In  the  case  of  an  ordinary  flea-bite,  then,  the  injury  is  not  confined  to 
the  particular  portion  of  tissue  transfixed  and  injured  by  the  lancet,  but 
the  disturbance  extends  some  distance  around.  Those  who  have  not 
studied  flea-bites  should  do  so,  and  I  need  hardly  assure  you  that  you 
have  abundant  opportunities  in  the  wards  of  the  hospital  for  the  observa- 
tion of  flea-bites  in  every  state  of  change — from  the  most  recently  inflicted 
injury  to  the  case  in  which  the  redness  is  disappearing  and  the  bright  red 
tint  is  giving  place  to  the  ordinary  color  of  the  adjacent  skin. 

If  in  a  recent  bite  you  carefully  notice  the  redness,  you  will  observe 
that  the  red  blush  ceases  at  a  definite  line;  the  red  tint  does  not  grad- 
ually shade  off  into  the  hue  of  the  surrounding  skin,  but  the  red  limit- 
ing line  is  abrupt,  and,  if  the  skin  happens  to  be  pale,  what  is  seen  is  a 
little  circular  patch  about  the  one-eighth  of  an  inch  or  more  in  diam- 
eter. This  area  is  of  a  bright  red  color,  almost  as  red  as  the  cheek,  and 


OCCURRING  IN  A   FLEA-BITE.  22$ 

if  you  look  closely  you  may  often  see  a  dark  spot  in  the  centre,  which, 
as  I  have  said,  is  the  perforation  made  by  the  lancet  of  the  animal,  ren- 
dered evident  by  the  passage  into  it  of  a  little  blood.  Now  there  is  no 
doubt  that  the  redness  depends  upon  the  distention  of  the  capillaries  by 
blood.  These  little  vessels  obviously  contain  much  more  blood  than 
they  do  in  their  usual  state.  As  regards  the  precise  manner  in  which 
this  redness  is  produced  there  is,  however,  room  for  some  difference  of 
opinion,  and  we  have,  indeed,  yet  much  to  learn  in  connection  with  this 
interesting  phenomenon.  There  can  be  no  doubt  that  the  capillaries  of 
the  red  area  contain  twice  or  three  times  as  much  blood  as  the  adjacent 
capillaries  of  the  skin.  Now  you  are  probably  aware  that  when  we  blush, 
the  cutaneous  capillaries  of  the  cheeks  are  suddenly  distended,  and  their 
diameter,  of  course,  is  considerably  increased.  If  it  were  not  so,  the 
difference  in  the  quantity  of  blood  would  not  be  sufficient  to  produce 
the  intensity  of  color  which  is  so  remarkable. 

You  see,  then,  that  an  instrument  which  is  much  less  than  the  smallest 
needle,  having  passed  directly  through  the  skin,  has  quickly  led  to  dila- 
tation of  the  capillary  vessels  for  a  certain  distance,  perhaps  the  one- 
sixteenth  of  an  inch  or  more,  around  the  line  of  perforation  ;  but  none 
of  the  vessels  beyond  the  circumscribed  line  are  dilated,  though  they 
freely  communicate  with  the  dilated  vessels.  Does  this  action  depend 
upon  some  influence  exerted  upon  certain  fine  nerve-fibres  lying  in  the 
course  of  the  wound,  or  is  it  due  to  any  direct  influence  upon  the  vessels 
themselves?  This  last  suggestion  may  be  dismissed  at  once,  because  by. 
no  direct  influence  upon  vessels,  of  which  we  have  knowledge  can  such  a 
phenomenon  be  produced.  There  is  no  doubt,  whatever,  that  the  change 
in  the  diameter  of  the  vessels  is  occasioned  by  injury  to  the  nerves,  and 
it  is  probable  that  the  congestion  of  the  capillaries  depends,  not  upon 
injury  done  to  nerves  by  the  passage  of  the  lancet  of  the  flea,  but  upon 
the  influence  exerted  on  the  nerves  in  consequence  of  the  escape  of  a 
small  quantity  of  irritating  poisonous,  material,  which  is  extruded  at  the 
same  time,  and  poisons  and  irritates  the  nerves  in  the  course  of  the  wound 
and  those  at  a  short  distance  around  the  line' of  penetration,  and  thus 
causes  change  in  the  nerve-centre. 

Alterations  of  Calibre  of  the  Small  Arteries. — The  redness  of  the 
flea-bite  is  due  to  dilatation  of  the  capillaries ;  but  what  is  very  remark- 
able and  of  great  interest  is  this,  that  the  little  arteries  which  communi- 
cate with  and  supply  the  capillaries  with  blood  must  be  dilated  to  a  cer- 
tain definite  extent.  Of  this  you  may  convince  yourselves  by  trying  the 
following  little  experiment.  Press  the  finger  firmly  upon  the  skin  cor- 
responding to  the  flea-bite  and  skin  around  it,  so  as  to  drive  the  blood 
from  the  distended  vessels  into  the  neighboring  capillaries.  The  whole 
of  the  skin  subjected  to  pressure  of  course  becomes  perfectly  pale,  the 
area  corresponding  to  the  flea-bite  being  as  pale  as  the  skin  around,  from 
the  capillaries  of  which  the  blood  has  been  temporarily  driven.  Now  a 

P 


226  DEGREE   OF  CONTRACTION  OF  ARTERIES 

few  seconds  after  the  finger  has  been  removed,  the  blood  streams  back 
into  the  vessels  of  the  area  of  the  skin  rendered  white  by  the  pressure,  so 
as  to  restore  the  exact  tint  which  existed  before.  The  flea-bite  will  re- 
sume the  precise  degree  of  redness  it  had  before  pressure  was  applied, 
being  neither  paler  nor  darker.  The  pressure  has  caused  only  a  tempo- 
rary change.  Although  the  blood  had  been  completely  squeezed  out  of 
the  capillary  vessels,  the  moment  it  is  allowed  to  return  it  fills  'these  ves- 
sels and  distends  them  to  precisely  the  same  degree  of  dilatation  as 
before. 

By  this  simple  experiment  we  conclusively  prove  not  only  that  the 
capillary  vessels  are  dilated,  but  dilated  to  a  definite  extent,  so  that 
every  capillary  will  resume  the  same  diameter,  and  is  capable  of  retain- 
ing this,  at  any  rate,  for  some  hours,  though  the  blood  may  be  thoroughly 
squeezed  out  and  allowed  to  run  back  as  often  as  you  please.  How  is 
this  brought  about  ?  By  what  mechanism  is  it  effected  and  how  can  the 
phenomenon  be  accounted  for  ?  The  change  is  complex  and  not  to  be 
explained  in  a  few  words  ;  but  as  it  illustrates  some  very  important  phys- 
iological and  pathological  principles  the  matter  is  well  worthy  of  atten- 
tive consideration.  In  the  first  place,  we  must  take  note  of  the  condi- 
tions which  determine  and  regulate  the  flow  of  blood  at  a  certain  rate 
through  the  capillary  vessels,  and  these  are  somewhat  complex. 

The  capillaries  are  elastic  tubes,  which  have  no  power,  as  far  as  is 
known,  of  active  contraction.  They  can  be  distended,  and  they  will 
recoil  or  contract  so  as  to  be  very  much  less  than  their  ordinary  diam- 
eter, indeed,  they  may  be  so  reduced  as  to  appear  like  mere  lines,  their 
cavity  being  for  the  time  obliterated,  and  not  a  blood-corpuscle  passing 
through  them.  Nevertheless  the  capillary  has  no  active  power  of  con- 
traction or  dilatation.  Its  thin  walls  are  eminently  elastic,  and  yield  if 
blood  or  other  fluid  is  forced  into  the  tube  by  pressure.  If  they  are 
allowed  to  react,  the  fluid  will  be  gradually  expelled  and  the  cavity  of 
the  tube  almost  obliterated,  the  capillary  vessel  looking  like  a  fine  cylin- 
drical cord.  If  the  little  arteries  are  distended  and  enlarged,  more  blood 
will  be  permitted  to  pass  into  the  capillaries,  and  these  tubes  will  be 
distended  and  their  walls  stretched.  If  the  diameter  of  the  arteries 
becomes  reduced,  the  capillaries  will  shrink.  These  phenomena  are 
repeated  whenever  the  pressure  by  which  the  blood  is  forced  into  the 
vessels  is  reduced  or  increased. 

The  Degree  of  Contraction  of  the  Minute  Arteries  deter?nined  and 
maintained  by  Nerve  Action. — And  now  as  to  the  vessels  which  pour 
their  blood  into  the  capillaries.  The  smaller  arteries,  we  know,  are 
capable  of  undergoing  very  great  alterations  in  calibre,  the  alterations 
being  of  an  active  character.  By  active  I  mean  that  the  diameter  of  a 
small  artery  can  be  maintained  for  a  time  at  a  certain  uniform  standard, 
the  canal  being  completely  obliterated,  or  increased  to  twice  the  area  of 
its  usual  section,  or  half  the  area,  as  the  case  may  be,  and  this  irrespec- 


DETERMINED  BY  NERVE-ACTION.  22/ 

tive  of  any  temporary  changes  produced  by  mechanical  pressure  applied 
from  time  to  time. 

The  smaller  arteries  are  encircled  by  numerous  muscular  fibres,  placed 
as  close  as  possible  to  one  another,  often  arranged  in  very  many  layers. 
This  muscular  tissue  constitutes  the  greater  part  of  the  thickness  of  the 
arterial  walls.  An  idea  may  be  formed  of  the  arrangement  of  the  mus- 
cular fibre-cells  of  a  small  artery,  and  of  the  manner  in  which,  by  con- 
tracting, the  tube  of  the  vessel  may  be  constricted,  and  of  the  mode  of 
distribution  of  the  nerve-fibres,  if  the  accompanying  figure,  p.  229,  be 
carefully  examined.  When  the  encircling  muscular  fibres  contract,  the 
tube  of  the  artery  is,  of  course,  diminished.  When  the  muscular  fibres 
undergo  relaxation,  the  tube  of  the  vessel  will  be  enlarged. 

The  calibre  of  the  artery  is  entirely  dependent  upon  varying  degrees 
of  contraction  or  relaxation  in  the  contractile  fibres,  and  the  change 
takes  place  in  all  little  arteries  from  time  to  time.  This  is  not  a  passive 
change,  like  the  mere  dilatation  and  recoil  of  the  elastic  capillary  vessels, 
but  a  change  due  to  varying  degrees  of  contraction  or  relaxation  of  the 
muscular  fibres  which  encircle  the  tube,  and  which  may  be  retained  at 
a  precise  point  without  the  least  variation  in  extent  or  vigor  for  a  con- 
siderable time.  The  contraction  of  the  muscular  fibres  may  even  remain 
constant  in  spite  of  an  alteration  in  the  pressure  by  which  the  blood  is 
driven  into  the  tubes.  • 

Next,  we  must  inquire  by  what  means  a  definite  degree  of  contraction 
and  relaxation  of  the  muscular  fibres  of  the  little  arteries  is  determined. 
It  has  been  conclusively  proved,  partly  by  the  results  of  experiment  and 
partly  by  reasoning  based  upon  the  fact  of  the  arrangement  and  distri- 
bution of  nerves  to  muscular  fibres,  which  has  been  demonstrated  by 
microscopical  investigation,  that  the  Avonderful  changes  in  question  are 
brought  about  through  the  instrumentality  of  nerves  and  nerve-centres 
only.  For  every  set  of  minute  arterial  vessels  there  is  a  nerve-centre, 
and  by  alteration  in  the  condition  of  this  nerve-centre  the  calibre  of  the 
little  arteries,  or,  in  other  words,  the  degree  of  contraction  of  the  mus- 
cular fibres  of  their  coats,  will  be  determined.  Each  nerve-centre  is 
connected  with  other  centres  by  intercommunicating  fibres,  so  that  a 
very  few  arteries  only  may  have  their  calibre  altered,  or  the  change  may 
occur  in  hundreds  and  thousands  of  vessels,  distributed  to  a  large  extent 
of  tissue  at  the  same  moment. 

Everything  I  am  telling  you  is  based  on  observation  and  experiment, 
and  I  shall  be  able  to  show  you  in  microscopical  preparations  the  actual 
nerve-fibres  concerned.  We  can  easily  demonstrate  the  muscular  fibres 
of  the  minute  arteries  of  the  body  of  man  and  vertebrate  animals  gener- 
ally. We  know,  too,  that  there  are  nerves  abundantly  distributed  to 
these  arteries,  and  that  the  nerves  are  connected  with  ganglia. 

Of  the  Ganglia  governing  and  regulating  the  Calibre  of  the  small 
Arteries. — In  manv  instances  I  have  followed  fine  nerve-fibres  distributed 


228  DISTRIBUTION  OF  NERVES    TO  ARTERIES. 

to  the  muscular  fibres  of  a  minute  artery  for  a  long  distance,  and  have 
traced  them  to  their  origin  in  an  individual  nerve-cell  in  the  nerve-centre. 

The  nerve-centres  connected  with  these  and  other  nerve-fibres  con- 
cerned in  governing  and  regulating  the  flow  of  blood  through  the  arte- 
ries and  capillaries  are  extremely  numerous.  The  arrangement  of  the 
centres  or  ganglia  and  of  the  entering  and  emerging  nerve-fibres  can  be 
most  easily  studied  in  the  coats  of  the  intestine  of  any  small  animal; 
but  for  investigating  the  structure  of  the  nerve-cells  themselves,  the  little 
green  tree-frog  (Hyla  viridis)  should  be  selected.  If  you  examine  the 
.mesentery  near  the  intestine  of  this  animal  and  the  areolar  tissue  in  the 
back  part  of  the  abdominal  cavity,  you  will  find  the  ganglia  as  numerous 
as  is  indicated  in  this  drawing.  If  you  take  a  portion  of  the  mucous 
membrane  of  the  small  intestine  of  man,  or  of  one  of  the  higher  ani- 
mals, say  not  more  than  a  quarter  of  an  inch  square,  and  prepare  it  care- 
fully, you  may  find  from  half  a  dozen  to  a  dozen  or  more  ganglia.  Each 
ganglion  will  contain  from  two  or  three  to  two  or  three  hundred  cells, 
and  every  individual  cell  will  have  at  least  two  fibres  issuing  from  it.* 
By  this  investigation  you  will  be  able  to  gain  a  correct  notion  of  the 
general  nature  and  structure  of  the  nervous  apparatus  which  exerts  an 
influence  upon  every  part  of  the  vascular  system,  and  particularly  of  the 
finest  ramifications  of  the  nerves  distributed  to  the  walls  of  the  small 
arteries,  veins,  and  capillaries,  and,  in  certain  cases,  to  the  tissues  which 
intervene  between  the  capillaries. 

Ganglia  and  intercommunicating  bundles  of  nerve-fibres  exist  in  every 
part  of  the  intestinal  canal  of  man  and  the  higher  animals.  Although 
no  nerve  ganglia  exist  very  near  the  ultimate  distribution  of  the  nerves 
to  the  small  arteries  of  the  skin  of  the  body  and  to  the  tissues  of  the 
limbs,  we  know  that  these  nerves  are  all  connected  with,  nerve-centres 
exhibiting  the  same  general  structure  and  arrangement  as  those  found  in 
connection  with  the  mucous  membrane  of  the  intestines  and  other  viscera 
of  the  abdomen  and  thorax.  All  belong  to  the  so-called  Sympathetic 
system.  Nerve-centres  or  ganglia  are  placed  in  certain  special  parts  of 
the  trunk,  and  from  these  bundles  of  nerve-fibres  are  derived  which  are 
distributed  to  the  vessels  of  the  head  and  extremities.  The  minute 
arteries  by  which  blood  is  distributed  to  the  muscles  of  the  limbs,  to  the 
large  nerves,  to  the  brain  and  spinal  cord  and  their  membranes  are  as 
fully  supplied  with  nerves,  and  are  as  much  under  the  influence  of  nerve 
ganglia  of  the  sympathetic  system,  as  are  the  arteries  of  the  lungs  or  the 
heart,  or  those  of  the  liver,  kidney,  or  other  secreting  organs. 

I  propose  now  to  describe  more  fully  the  mechanism  by  which  the 
varying  calibre  of  the  small  arteries  is  determined.  You  will  form  a 
correct  idea  of  the  degree  to  which  little  arteries  may  contract  if  you 
take  note  of  what  is  represented  in  this  drawing  (not  introduced  in  this 

*  "  Phil.  Trans.,"  May,  1863. 


DISTRIBUTION  OF  NERVE-FIBRES  TO  SMALL  ARTERY. 
<*  FIG.  I. 


A  small  artery  from  the  bladder  of  the  hyla  or  green  tree-frog,  showing  the  distribution  of  fine 
nerve-fibres  to  the  muscular  fibre  cells  of  the  vessel.  The  nerve-fibre  can  be  followed  from  the  nerve 
trunk  a  to  the  vessel.  In  the  connective  tissue  to  the  left  are  seen  two  muscular  fibre  cells  with  nerve- 
fibres  distributed  to  them.  These  belong  to  the  tissue  to  which  the  artery  was  distributed,  and  are  not 
connected  with  the  vessel.  X  215-  About  the  middle  of  the  figure  the  tube  is  somewhat  constricted, 
in  consequence  of  slight  contraction  of  the  muscular  fibre  cells  in  this  part  of  the  artery. 

nfas  of  an  inch X  215- 

2O  229 


230  THE  NERVE-FIBRES   OF  CAPILLARIES. 

work)  of  the  arteries  of  the  Pia  mater  of  the  common  sheep,  which  were 
injected,  immediately  after  the  death  of  the  animal,  with  Prussian  Blue 
fluid.  (For  the  composition  of  this  fluid  and  the  method  of  injecting, 
see  "  The  Microscope  in  Medicine,"  or  "  How  to  Work  with  the  Micro- 
scope.") The  walls  of  the  vessels,  with  their  muscular  fibre-cells,  are 
well  shown.  The  little  arteries  at  the  time  of  death  have  contracted, 
so  as  to  produce  great  irregularity  in  the  calibre  of  the  arteries.  You 
see  in  one  place  the  muscular  fibres  of  a  considerable  length  of  the 
vessel  have  vigorously  contracted,  so  as  to  obliterate  the  canal.  Very 
few  blood-corpuscles  could  have  passed  through  this  part  of  the  vessel 
at  the  time  of  the  contraction  of  its  muscular  fibres.  This  firmly  con- 
tracted portion  of  the  little  artery  is  immediately  continuous  with  another 
part  of  the  vessel  where  the  coats  are  relaxed,  and  the  diameter  of  the 
tube  here  would  be  perhaps  twenty  times  that  of  its  continuation  in  the 
contracted  portion  of  the  vessel.  Many  different  portions  of  small 
arteries  in  various  degrees  of  contraction  are  represented  in  different 
parts  of  the  drawing.  (A  very  slight  degree  of  contraction  is  seen  in 
the  little  artery  figured  on  page  229.) 

We  must  yet  go  somewhat  more  into  detail  before  we  can  expect  to 
find  an  adequate  explanation  of  the  changes  which  take  place  in  the 
coats  of  the  small  arteries  during  life,  by  which  variations  in  their  calibre 
are  determined,  and  which  are  intimately  connected  with  the  causation 
of  the  phenomena  of  the  flea-bite.  It  must  be  borne  in  mind  that  the 
arteries  are  not  the  only  small  vessels  which  are  supplied  with  nerve- 
fibres.  It  has  long  been  known  that  to  the  coats  of  the  small  veins 
nerve-fibres  are  abundantly  distributed,  but  the  general  arrangement  of 
the  finest  fibres  has  not  been  fully  investigated.  They  exist  in  great 
number,  and,  indeed,  in  much  greater  number  than  would  be  expected, 
considering  the  paucity  of  the  muscular  fibres  of  the  veins  and  the  thin- 
ness of  the  coats  of  these  vessels.  From  the  great  number  of  the  nerve- 
fibres  one  would  incline  to  the  notion  that  some  were  concerned  in 
transmitting  impressions  to  the  nerve-centre.  If  all  are  motor  fibres, 
their  number  in  proportion  to  the  amount  of  muscular  tissue  is  far 
greater  than  elsewhere.  But  besides  the  distribution  of  nerves  to  small 
arteries  and  veins,  I  must  beg  you  to  pay  attention  to  the  arrangement 
of  the  nerve-fibres  which  belong  to  the  capillary  vessels. 

Of  the  Nerves  of  Capillary  Vessels. — You  will  not  find  it  stated  in 
any  of  your  text-books,  even  at  this  time,  that  nerve-fibres  are  distributed 
to  capillaries.  Not  only  is  this  the  fact,  but  upon  many  capillaries  a 
considerable  number  of  fine  nerve-fibres  may  be  seen  to  ramify.  As 
long  ago  as  1860  I  succeeded  in  demonstrating  this  new  set  of  nerve- 
fibres,  distributed  to  the  capillary  vessels,  which  had  not  been  previously 
described.  Numerous  observations  upon  the  capillary  vessels  of  various 
vertebrate  classes  have  convinced  me  that  the  capillaries  of  vertebrate 
animals  generally  are  freely  supplied  with  nerves;  or,  to  speak  more 


NERVES   OF  CAPILLARY   VESSELS. 


231 


accurately,  that  just  outside,  or  at  a  short  distance  from  the  'outer  sur- 
face of  the  walls  of  the  capillaries,  very  fine  nerve-fibres  exist,  which 
in  many  cases  form  a  lax  network  or  plexus  of  extremely  delicate  nerve- 
fibres  on  the  outer  surface  of  the  vessel. 

The  fact  is  not  of  anatomical  interest  only,  but  the  distribution  of 
the  nerve-fibres  in  question  has  an  important  bearing  upon  questions 
concerning  the  action  of  the  minute  vessels  during  life.  Upon  carefully 
examining  capillaries  in  many  tissues  of  the  frog,  according  to  the  plan 
I  have  described  in  "Microscope  in  Medicine"  and  "How  to  Work 
with  the  Microscope,"  you  will  meet  with  little  difficulty  in  demonstrat- 
ing the  nerve-fibres  to  capillary  vessels.  I  could  show  you  more  than 

FIG.  2. 


From  an  interval  between  the  fibres  of  the  mylohyoid  muscles  of  the  hyla,  a.  Trunk  of  fine  dark- 
bordered  nerve-fibres  with  fine  fibres  coming  from  them,  one  of  which  may  be  traced  to  the  capillary 
b,  while  others  are  distributed  to  the  muscular  fibres,  which  are  not  represented  in  the  drawing.  Th •; 
arrangement  of  the  nerves  supplying  the  capillary  vessel  is  well  seen.  From  a  specimen  mounted  in 
glycerine  and  more  than  ten  years  old.  X  2I5' 

twenty  preparations  from  the  frog  in  which  branches  of  nerve-fibres  to 
the  capillary  vessels  are  seen,  without  the  slightest  doubt.  The  fact  can- 
not be  explained  away.  There  is  no  question  whatever  about  the  deli- 
cate fibres  in  question  being  nerves,  because  in  many  instances  I  have 
been  able  to  trace  the  fibres  from  their  distribution  outside  the  capil- 
laries to  their  connection  with  the  ganglion  cell,  without  one  break  in 
the  continuity  of  the  matter  of  which  they  consist.  But  many  will  not 
believe  that  a  structure  which  may  be  demonstrated  in  a  cold-blooded 
vertebrate  animal  like  the  frog  necessarily  exists  in  the  higher  vertebrata 
and  in  man.  I  have,  however,  succeeded  in  demonstrating  nerves  to 
capillary  vessels  in  several  mammalian  animals  and  birds,  and  have  been 
able  to  permanently  preserve  several  of  the  specimens.  One  of  the  best 
animals  for  the  investigation  is  the  white  mouse,  because  there  is  very 
little  connective  tissue  in  this  animal  to  obscure  the  extremely  delicate 
nerve-fibres.  Upon  the  whole,  however,  I  prefer  the  bat's  wing ;  and  of 
the  arrangement  of  the  nerves  upon  the  capillaries  and  in  other  tissues 


232  MECHANISM  OF  CAPILLARY  CIRCULATION. 

connected  with  the  thin  membrane  of  this  wonderful  organ  I  have  pre- 
served several  specimens.  I  have  represented  a  very  clear  specimen  in 
the  accompanying  figures  3,  4.  It  has  been  magnified  only  215  ;  but  to 
see  the  points  clearly  a  magnifying  power  of  700  is  required. 

Of  Demonstrating  the  Nerves  distributed  to  Capillaries. — In  order  to 
see  the  delicate  nerve-fibres  and  the  capillary  vessels,  it  is  necessary  to 
obtain  a  structure  in  which  the  capillaries  themselves  can  be  seen  with- 
out much  dissection  or  the  necessity  of  section  cutting ;  for  if  you  have 
to  dissect  the  tissue,  you  will  tear  the  capillaries,  and  then  you  will  not 
be  able  to  follow  the  nerve-fibres  for  any  great  distance.  In  the  bat's 
wing,  and  also  in  the  bladder  of  the  frog,  you  have  a  natural  dissection 
almost  ready  for  observation.  (Arrangement  shown  in  several  enlarged 
copies  of  drawings.) 

Of  the  arrangement  of  nerve-fibres  in  a  tissue,  a  considerable  extent 
of  which  is  altogether  destitute  of  capillary  vessels,  one  can  hardly  point 
to  a  better  illustration  than  is  afforded  by  the  cornea  of  a  small  animal, 
particularly  the  hyla  or  little,  green  tree-frog.  The  nerve-fibres  in  this 
transparent  fibrous  tissue  are  exceedingly  numerous,  forming  extensive 
networks  of  wonderfully  delicate  nerve-fibres,  with  which,  at  short  in- 
terval's, small  masses  of  bioplasm  are  connected.  From  these  the  fibres 
grow,  and  the  net-work  of  nerve-fibres  increases  in  extent  a's  the  cornea 
expands  in  dimensions.  A  thin  section,  which  includes  the  anterior 
surface  of  the  cornea  (placed  uppermost  so  as  to  be  just  beneath  the 
thin  glass  cover)  is  most  favorable  for  observation.  High  powers  ought 
to  be  used  (from  300  to  1,200  diameters).  In  such  a  specimen  you  can 
trace  all  that  is  represented  in  my  drawings.  The  nerves  divide  and 
subdivide  at  short  intervals,  and  extensive  networks  of  excessively  fine 
fibres  are  formed,  which  lie  on  different  planes,  and  are  to  be  found  in 
every  part  of  the  corneal  tissue,  though  the  networks  are  more  numerous 
near  the  anterior  surface  than  in  other  parts.  These  nerve-fibres  might 
be  regarded  as  extensions  of  those  belonging  to  capillary  vessels.  At 
the  margin  of  the  cornea  some  are  undoubtedly  continuous  with  the 
latter,  but  many  of  the  nerve-fibres  of  the  corneal  tissue  may  be  fol- 
lowed to  bundles  of  nerve-fibres  at  the  margin  of  the  cornea. 

Of  the  Mechanism  by  which  the  Capillary  Circulation  of  Man  and 
Animals  is  regulated. — My  chief  object  in  troubling  you  with  this  some- 
what detailed  anatomical  description  is  that  I  maybe  able  to  explain  the 
probable  action  of  these  fine  nerve-fibres  distributed  to  the  capillary  ves- 
sels, and  give  some  account  of  the  very  important  office  they  discharge 
during  life.  It  is  true  that  much  of  this  discussion  strictly  belongs  to 
the  province  of  physiology,  but  inasmuch  as  the  inquiry  has  a  most  im- 
portant bearing  in  connection  with  the  determination  of  the  nature  of 
the  phenomena  occurring  in  the  simplest  pathological  changes,  in  a  flea- 
bite  for  example,  I  shall  make  no  apology  for  referring  to  it  here.  With- 
out the  facts  above  referred  to,  and  deprived  of  the  inferences  deduced 


CAPILLARY  VESSELS   AND   NERVE-FIBRES   FROM   THE 
BAT'S  WING. 


FIG.  3. 


Capillaries  and  very  fine  nerve-fibres  distributed  to  the  bat's  wing.  In  many  parts  of  the  specimen 
the  nerve-fibre  could  be  followed  from  a  bundle  of  fine  nerve-fibres  to  the  capillaries.  Two  instances 
of  this  are  shown  in  the  drawing. 

•f^fj,  of  an  inch X  215. 


FIG.  4. 


A  small  part  of  Fig.  3  highly  magnified.  The  distribution  of  the  nerve-fibres  to  the  capillary  and 
their  relation  to  its  walls  are  well  seen.  The  mode  of  branching  and  division  of  some  of  the  finest 
nerve-fibres  are  also  well  shown  in  the  lower  part  of  the  drawing.  X  7°°. 

20*  233 


234 


ARRANGEMENT  OF  NERVE-FIBRES. 


from  these  observations,  I  should  be  unable  to  explain  to  you  the  phe- 
nomena of  inflammation  or  fever  as  these  pathological  changes  occur  in 
man  and  warm-blooded  animals.  In  order  to  make  my  meaning  clear, 
I  must  refer  to  this  diagram,  which  is,  as  it  were,  made  up  from  obser- 
vations actually  carried  out  on  several  different  specimens. 

FIG.  5. 


I. 


2. 


Diagram  to  show  self-regulating  mechanism  connected  with  the  minute  arteries  and  capillaries. 
a,  artery  with  muscular  fibre-cells;  the  dark  lines  show  its  diameter  when  dilated,  b,  small  vein. 
c,  capillary  net-work.  Over  No.  I  the  capillaries  are  dilated  and  over  No.  2  they  are  contracted,  d  is 
a  ganglion  cell  with  at  least  two  sets  of  nerve-fibres  connected  with  it,  one  of  which,  e,  divides  and 
subdivides,  giving  off  nerve-fibres,  which  are  distributed  to  the  artery  a,  while  the  other,/",  is  contin- 
uous with  the  plexus  of  nerve-fibres  ramifying  cl«se  to  the  capillary  vessels.  Nerve-fibres  are  also 
distributed  to  the  small  vein,  b,  but  these  are  not  represented  in  the  drawing.  The  bioplasm  of  the 
vessels  and  nerve-fibres  is  shown. 

The  vessel  to  the  left,  b,  is  intended  to  represent  a  small  vein,  while 
that  marked  a  is  a  small  artery,  and  the  net-work  of  small  tubes  below, 
which  are  continuous  with  both  vessels,  are  the  capillaries,  outside  which 
you  see  here  and  there  delicate  fibres,  nerve-fibres.  These  are  really 
distributed  to  the  capillary  vessels  in  very  much  the  same  manner  as  is 
represented  here.  The  nerve-fibres  distributed  to  the  capillary  vessels 
join  to  form  a  fine  nerve-trunk,  and  are  by  continuous  fibres  connected 
with  a  cell,  d,  of  the  nerve-centre,  e  is  the  nerve-fibre  distributed  to 


OUTSIDE    THE    CAPILLARIES.  235 

the  artery,  and /is  that  connected  with  the  branches  distributed  to  the 
capillaries]  those  capillaries  near  the  vein,  over  i,  being  distended,  so 
that  the  nerve-fibres  are  nearly  in  contact  with  their  walls;  while  those 
over  2  are  contracted,  and  a  considerable  interval  is  seen  to  exist  be- 
tween the  outer  surface  of  these  and  the  nerve-fibres  distributed  to  them. 

The  greater  part  of  the  nerve-circuit,  which  I  have  endeavored  to 
depict,  has  been  demonstrated  by  actual  observation,  but  there  is  a 
break  or  hiatus  as  regards  the  connection  of  the  particular  fibres  distrib- 
uted to  the  artery  and  those  to  the  capillary,  with  the  nerve-cell.  One 
cannot  identify  the  afferent  fibre  and  the  efferent  branch  connected  with 
the  very  same  cell  as  is  here  represented.  There  is  no  doubt  whatever 
as  regards  the  existence  of  two  fibres  in  connection  with  each  nerve-cell 
in  any  nerve-centre.  Nor,  as  I  have  already  stated,  is  there  any  doubt 
about  the  connection  of  one  of  these  fibres  with  the  fine  nerve-fibres 
which  are  distributed  to  the  artery,  for  the  continuity  has  been  demon- 
strated. The  ramifications  of  the  fine  nerve-fibres  upon  and  amongst 
the  muscular  fibres  of  the  artery  have  also  been  demonstrated  in  numer- 
ous specimens  from  representatives  of  the  different  classes  of  Vertebrata. 
I  have  not  succeeded  in  tracing  the  nerve-fibres  from  capillary  vessels  to 
the  same  identical  nerve-cell  as  that  from  which  the  nerve  distributed  to 
the  little  artery  which  subdivides  into  the  capillaries  takes  its  rise.  I  con- 
sider the  arrangement  to  be  as  follows :  The  very  fine  nerve-fibres  which 
I  have  shown  to  be  distributed  to  capillary  vessels  are  probably  afferent. 
These  transmit  centripetally  to  the  nerve-cell  impressions  from  the  sides 
and  immediate  neighborhood  of  the  capillary  vessels,  and  from  the' tis- 
sues between  the  capillary  vessels.  In  the  cells  of  the  nerve-centre  a 
change  takes  place  whenever  the  peripheral  ramifications  of  these  affer- 
ent nerve-fibres  from  the  capillaries  are  irritated.  In  consequence  of  this 
change  effected  in  the  nerve-centre,  an  impulse  to  movement  is  trans- 
mitted by  the  nerves,  which  are  at  length  distributed  to  the  muscular 
fibres  of  the  little  artery,  when  the  muscular  fibres  will  contract,  and  the 
tube  of  the  artery  will  be  reduced  in  diameter.  The  calibre  of  the  artery 
is  at  once  reduced,  and  the  blood  stream  which  flows  onward  into  the 
capillary  vessels  is  diminished  ;  or,  in  other  words,  the  quantity  of  blood 
passing  to  a  given  area  of  tissue  in  a  given  period  of  time  is  much  re- 
duced. 

Under  other  circumstances  the  nerve-fibres  distributed  to  the  capillary 
vessels,  instead  of  being  irritated,  experience  a  paralyzing  influence,  in 
consequence  of  which  a  corresponding  action  is  produced  in  the  nerve- 
centre,  and,  instead  of  contraction,  we  have  relaxation  of  the  muscular 
fibres  of  the  little  artery;  and  the  quantity  of  blood  passing  through 
the  vessels  within  a  given  period  of  time  must  be  increased  to  an  extent 
proportionate  to  the  increased  diameter  of  the  vessel.  Here,  then,  is  a 
self-regulating  nervous  mechanism  connected  with  the  distribution  and 
regulation  of  the  blood-current  in  the  capillary  vessels  of  the  body  of  a 


236  CALIBRE    OF  ARTERIES 

most  efficient  kind,  coming  into  action  on  the  slightest  disturbance  of 
the  equilibrium  of  activity  either  at  the  peripheral  distribution  of  the 
nerves  or  in  the  nerve-centres  connected  with  them.  The  quantity  of 
blood  passing  through  these  vessels  can  be  regulated  to  a  nicety.  The 
stream  may  be  increased  or  diminished  suddenly,  or  an  uniform  flow 
maintained  for  a  considerable  period  of  time.  These  changes  are  brought 
about  solely  by  the  influence  of  the  nerves  in  determining  the  degree  of 
contraction  of  the  muscular  fibre  cells  which  encircle  the  artery. 

Let  us  now  apply  what  we  have  learned  to  the  phenomena  of  the  flea- 
bite  :  When  the  lancet  of  the  flea,  after  penetrating  the  cuticle,  reaches 
the  capillaries  of  the  skin,  some  of  the  fine  nerve-fibres  distributed  to 
the  capillaries  will  be  severed,  others  no  doubt  being  stretched  or  pressed 
upon  by  the  blood  and  fluid  which  escape  from  the  vessels,  and  in  conse- 
quence of  the  distention  which  the  latter  undergo.  The  result  is -a  relax- 
ing or  paralyzing  action  upon  the  nerve-centre.  The  efferent  nerves 
being  thus  influenced,  the  muscular  fibres  of  the  little  arteries  yield,  and 
become  flaccid  and  elongated.  Hence  the  diameter  of  the  tube  of  the 
vessel  will  become  largely  increased.  A  greater  quantity  of  blood  will 
flow  into  the  capillaries,  and  these  vessels  will  in  consequence  become 
distended.  This  action  probably  depends  partly  upon  severance  of  fine 
nerve-fibres  by  the  cutting  action  of  the  lancet  of  the  animal,  but  it  is 
in  part  due  to  the  influence  of  poison  expelled  at  the  moment,  which 
spreads  for  a  short  distance  among  the  elements  of  the  adjacent  tissues, 
perhaps  acting  chemically  on  the  nerve-fibres  or  on  their  bioplasm,  and 
causing  a  paralyzing  influence. 

But  what  is  highly  interesting  and  very  remarkable  is  this :  The  relax- 
ing or  paralyzing  action  is  exerted  to  a  definite  extent,  and  maintained 
without  variation  at  a  given  point  for  some  time.  The  dilatation  of  the 
little  arteries  is  effected,  and  the  degree  of  constriction  exerted  by  the 
muscular  coat  is  altered  for  a  time.  The  muscular  fibres  yield  accord- 
ing to  the  degree  of  paralyzing  influence  produced  upon  the  afferent 
nerves  at  the  seat  of  injury.  That  the  degree  of  dilatation  does  not 
vary  from  moment  to  moment  may  be  proved  in  a  very  simple  manner. 
If  you  squeeze  the  little  vessels  of  the  congested  area  of  skin  by  pressing 
firmly  for  a  second  or  two  with  one  finger,  so  as  to  drive  the  blood  out 
of  the  vessels,  the  whole  of  the  skin  subjected  to  the  pressure  will  be 
seen  at  the  moment  when  this  is  removed,  to  be  uniformly  pale.  In  a 
few  seconds,  however,  after  the  pressure  has  been  withdrawn,  the  blood 
will  re-enter  the  vessels,  and  the  inflamed  area  will  resume  its  redness, 
while  the  surrounding  skin  will  regain  its  original  tint.  The  varying 
degrees  of  redness  observed  in  different  flea-bites  are  due  entirely  to  the 
varying  degree  of  dilatation  of  the  hundreds  of  little  arteries  which  sup- 
ply the  capillary  vessels  of  the  inflamed  area.  The  distention  of  the 
capillaries  varies  according  to  the  calibre  of  the  arteries,  and  is  there- 
fore entirely  under  nerve  control.  If  complete  paralysis  of  the  nerve- 


ALTERED  BY  LOCAL   INJURY. 

fibres  distributed  to  the  little  arteries,  or  of  the  centres  from  which  they 
emanate,  were  to  occur,  the  capillaries  would  become  distended  to  the 
utmost  limit,  and  the  circulation  through  them  would  cease.  The  sur- 
rounding tissues  deprived  of  their  blood  supply  would  become  disorgan- 
ized, and  might  at  once  pass  into  a  gangrenous  state,  or  might  slowly 
degenerate  and  waste.  Such  is  the  nature  of  the  very  important  vascu- 
lar phenomena  which  occur  in  all  cases  of  inflammation,  and  which,  when 
affecting  a  considerable  extent  of  tissue,  may  cause  serious  structural 
changes,  and  result  in  the  development  of  chronic  disease,  or,  where 
certain  important  organs  are  affected,  may  cause  even  sudden  death. 

General  Vascular  Disturbance  resulting  from  Local  Injury. — But  in 
many  instances,  the  result  of  the  local  injury  is  much  more  widely  spread. 
In  some  cases  this  is  due  to  poison  being  introduced  into  the  blood,  so 
that  the  whole  mass  of  nutrient  fluid  is  poisoned,  and,  through  it, 
every  tissue  and  organ  of  the  body  may  suffer.  But  there  are  not  a  few 
instances  in  which  the  facts  cannot  be  thus  explained,  but  seem  rather 
to  be  due  to  the  same  series  of  changes  which  occur  in  an  ordinary  flea- 
bite,  the  action  being  more  intense.  The  bite  of  a  gnat,  the  sting  of  a 
bee,  wasp,  or  hornet,  will  occasion  phenomena  in  connection  with  the 
vessels  of  the  same  kind,  but  more  serious  and  extensive  than  the  injury 
inflicted  by  the  lancet  of  the  flea.  Such  local  injuries  may  cause  dilata- 
tion of  the  little  arteries  and  capillaries  over  a  considerable  portion  of 
the  body.  In  consequence  of  the  bite  of  an  ordinary  gnat,  the  whole 
of  one  arm  may  become  enormously  swollen.  So  large  a  quantity  of 
exudation  may  escape  from  the  vessels,  that  the  areolar  tissue  of  the  limb 
may  be  much  distended,  the  elements  of  the  tissues  generally  being  in 
a  state  of  tension,  their  action  much  deranged  or  entirely  marred.  In 
short,  a  condition  of  very  acute  and  serious  inflammation  may  result. 

In  such  a  case,  I  think  that  the  more  extensive  local  mischief  is  per- 
haps due  to  a  more  severe  and  more  extensive  local  change  having  been 
produced  at  the  seat  of  injury.  Instead  of  derangement  of  the  action 
of  the  vessels  of  a  very  limited  area  of  skin,  as  in  the  flea-bite,  we  have 
evidence  of  extensive  disturbance  in  the  circulation  affecting  small  arter- 
ies, capillaries,  and  veins  of  the  tissues,  of  part  of  a  limb  or  of  the 
entire  limb.  The  influence  is,  however,  still  limited,  and  such  a  case 
must  be  distinguished  from  those  in  which  the  tissue-changes  result  from 
the  whole  mass  of  the  blood  being  poisoned.  As  a  general  rule,  a  gnat- 
bite  does  no  harm  whatever.  Most  of  us  have  been  bitten  over  and  over 
again  ;  and  I  dare  say  some  have  carefully  watched  the  interesting  opera- 
tion performed  by  the  insect,  and,  when  the  instrument  has  been  care- 
fully inserted  through  the  cuticle,  and  into  the  true  skin,  have  felt  the 
pricking  sensation  which  indicates  the  arrival  of  its  point  at  the  nerve- 
fibres  adjacent  to  the  capillary.  Then  follows  the  perforation  of  the 
capillary,  and  soon  the  blood  will  be  seen  to  ascend,  and  you  will  notice 
the  abdominal  cavity  of  the  insect  becoming  gradually  distended  by  the 


238  GENERAL    CHANGES  FROM  LOCAL   INJURY. 

inflowing  blood.  In  a  short  time  the  creature  is  satisfied,  and,  after  care- 
fully withdrawing  his  proboscis,  he  contentedly  flies  away,  though  slowly, 
for  his  body  will  be  more  than  twice  as  heavy  as  it  was  when  he  first 
attacked  you.  With  the  exception  of  slight  tingling,  which  lasts  for  a 
little  while,  no  further  effect,  as  a  general  rule,  will  be  produced ;  but  I 
know  persons  who  do  not  escape  so  easily.  Sometimes  a  single  gnat- 
bite  will  cause  the  whole  of  the  hand  and  arm  to  swell  enormously,  and 
the  state  of  inflammation  may  last  for  two  or  three  days,  and  may  be 
accompanied  by  much  pain.  A  similar  remark  applies  to  the  sting  of  a 
bee,  or  wasp  or  hornet.  Some  individuals  will  be  seriously  affected,  while 
others  will  escape  with  very  little  inconvenience.* 

Such  facts  are  not  incompatible  with  the  view  of  the  phenomena  being 
essentially  due  to  nerve  change,  and  we  have  ample  evidence  that  some 
persons'  nerves  are  much  more  susceptible  to  the  same  degree  of  irrita- 
tion, mechanical  or  chemical,  than  are  those  of  others.  A  mechanical 
injury  or  a  poisonous  influence  sufficiently  severe  to  cause  death  in  one 
case  might  scarcely  produce  any  serious  change  in  another.  It  is  possi- 
ble that  there  may  be  some  structural  difference  in  the  nervous  system 
of  the  two  persons,  but  it  is  perhaps  more  probable  that  the  cause  of  dif- 
ference in  the  results  is  deeper,  and  depends  upon  some  difference  in  the 
individuality  and  powers  of  the  bioplasm  of  the  nerve  of  a  nature  not 
to  be  rendered  evident  by  physical  investigation.  We  note  correspond- 
ing peculiarities  as  regards  the  action  of  medicine.  I  have  known  in- 
stances in  which  the  smallest  dose  of  Morphia  will  occasion,  within  three 
or  four  hours  of  its  being  swallowed,  dilatation  of  the  capillary  vessels 
of  the  greater  part  of  the  surface  of  the  body,  shown  by  a  diffused  red- 
ness in  patches.  Less  than  one-tenth  of  a  grain  of  Morphia  has  led  to  this 
result,  but  such  a  dose,  as  a  general  rule,  would  produce  only  a  very  slight 
effect,  or  the  person  might  be  unconscious  that  any  such  drug  had  been 

*  An  interesting  fact  has  been  made  out  by  Dr.  Manson,  in  China,  with  regard  to 
the  transference  by  gnats  of  embryonic  or  immature  entozoa  from  the  blood  of  the 
human  organism  to  water.  The  minute  Filaria  sanguinus  hominis  is  the  entozoon  in 
question.  It  exists  in  the  blood  in  certain  cases  in  immense  numbers,  and  has  been 
removed  from  the  circulating  medium,  and  transferred  to  the  situation  where  it  is  to 
undergo  further  change  in  the  remarkable  way  just  referred  to.  An  excellent  resumt 
of  what  is  known  concerning  this  entozoon  will  be  found  in  a  paper  read  at  the  Epi- 
demiological  Society,  by  Sir  Joseph  Fayrer,  and  published  in  the  "London  Lancet" 
for  February  8th,  1879. 

We  have  long  known  that  many  infectious  diseases  may  be  spread  by  the  agency  of 
insects,  but  here  we  have  an  insect  extracting  blood  from  the  interior  of  the  vessels, 
and  carrying  some  of  this  very  same  blood,  and  diffusing  any  special  living  particles  it 
may  contain  into  other  media,  where  these  organisms  may  pass  another  part  of  their 
existence,  and  possibly  grow  and  multiply.  It  is  obvious  that  other  living  disease- 
causing  organisms  may  be  distributed  far  and  wide  in  the  same  manner,  and  thus  many 
special  fevers,  and  inflammatory  diseases  occurring  in  man  and  animals,  and  depending 
upon  a  living  poison,  may  be  carried  to  a  distance,  and  preserved  for  long  periods  of 
time,  or  undergo  farther  development. 


FEVERS  AND  INFLAMMATIONS.  239 

given  at  all.  The  nerves  and  the  nerve-centres  connected  with  the  vas- 
cular system  exhibit  very  different  degrees  of  sensitiveness  or  suscepti- 
bility in-  different  persons. 

In  discussing  the  probable  nature  of  the  actual  changes  induced  by 
such  poisons,  which  act  upon  the  fine  ramifications  of  the  nerves  dis- 
tributed to  capillary  vessels,  we  have  to  consider: — i.  The  direct  local 
action  of  the  poisonous  material  on  the  nerve -fibres  and  other  tissues 
with  which  it  comes  at  once  into  contact ;  and,  2,  the  local  action  of 
the  poison  on  the  capillary  nerve-fibres  in  many  tissues  and  organs  of 
the  body  at  a"  distance  from  the  seat  of  injury,  through  the  contamina- 
tion of  the  whole  mass  of  the  blood. 

In  both  cases,  whether  the  action  be  local  or  general,  circumscribed 
or  diffused,  the  widest  difference  as  regards  the  degree  of  action  exerted 
by  the  same  poison  and  the  same  amount  of  poison  on  different  persons 
will  be  observed,  and  this  must  be  referred  to  the  peculiarity  of  constitu- 
tion of  the  individual,  to  the  degree  of  tolerance  his  nerves  may  have 
acquired  by  the  influence  of  previous  exposure,  and  a  number  of  other 
circumstances.  The  same  amount  of  poison  in  the  blood  may  be  suffi- 
cient to  cause  the  most  grave  symptoms  in  one  person  and  not  give  rise 
to  the  slightest  change  in  others. 

You  see  how  large  a  subject' is  opened  for  consideration  by  the  dem- 
onstration of  the  nerve-fibres  to  capillary  vessels,  and  what  a  number 
of  important  and  widely  separated  physiological  and  pathological  actions 
may  be  explained  and  accounted  for  by  the  influence  of  this  important 
part  of  the  nervous  system. 

OF  THE  FORMATION  OF  PUS  IN  AND  NEAR  THE  CAPILLARIES  IN 
INFLAMMATION  AND  FEVER. 

I  have  already  advanced  arguments  which,  as  it  seems  to  me,  fully 
justify  the  conclusion  that  fever  is  a  General  Inflammation,  while  inflam- 
mation is  to  be  regarded  as  a  Local  Fever.  Some  among  you  who  have 
considered  the  matter  may,  however,  object  to  this  inference,  on  the 
ground  that  what  is  known  as  "  pus"  is  a  very  constant  product  in  in- 
flammations, but  is  not  generally  formed  in  fever.  Such  an  objection 
will,  however,  disappear  if  we  study  the  mode  of  formation  of  this  liv- 
ing matter,  pus.  Indeed,  in  most  fevers  the  pathological  phenomena 
are,  happily,  not  sufficiently  intense.  The  changes  do  not  proceed  to 
the  extent  necessary  for  the  development  of  pus-corpuscles.  There  are, 
however,  fevers  in  which  the  development  of  pus  is  common  enough. 

In  Erysipelas,  which  may  be  correctly  included  under  fevers  or  inflam- 
mations, pus,  as  you  are  aware,  is  often  formed  to  an  extent  sufficient  to 
destroy  important  tissues  and  to  cause  death.  Some  of  you  of  late  years 
may  have  been  assured  that  erysipelas,  like  many  other  fevers  and  inflam- 
mations, is  due  to  the  presence  and  growth  and  multiplication  of  bacteria. 
The  process  of  suppuration  itself,  it  has  been  said,  is  occasioned  by  these 


24O  BIOPLASTS  PASSING   THROUGH  VESSELS. 

organisms.  I  have  already  treated  of  this  question  in  "  Disease  Germs  " 
and  elsewhere.  I  shall,  therefore,  only  remark  here  that,  in  my  opinion, 
there  is  no  reasonable  ground  for  either  hypothesis,  and  that  The  facts 
can  be  adequately  explained  without  invoking  the  aid  of  bacteria.  In 
the  course  of  the  changes  taking  place  in  erysipelas,  pus,  unfortunately, 
is  very  often  formed.  You  may  have  suppuration  of  the  tissues  in  the 
greater  part  of  the  affected  limb.  Indeed,  in  some  cases  the  areolar 
tissue  extending  over  a  considerable  part  of  the  body  may  be  the  seat 
of  the  formation  and  multiplication  of  pus-corpuscles. 

In  ordinary  fevers  life  is  usually  destroyed  before  that  degree  of  change 
which  involves  the  process  of  suppuration  has  been  reached.  If,  how- 
ever, severe  fever  lasted  for  a  considerable  period  and  life  was  sustained 
for  a  sufficient  time,  many  of  the  tissues  might  pass  into  the  state  of 
suppuration.  Such  is,  unfortunately,  but  too  frequent  in  very  severe 
cases  of  scarlet  fever,  in  which  disease  suppuration  sometimes  occurs  in 
several  of  the  joints,  besides  which  small  abscesses  are  not  unfrequently 
developed  in  many  different  parts  of  the  body.  It  is  easy  to  see  why 
suppuration  should  be  more  commonly  developed  in  connection  with 
intense  local  inflammation  than  in  the  more  widely  spread,  but  less  in- 
tense, action  which  occurs  in  fever.  In  inflammation  the  change  is  com- 
paratively circumscribed,  and  may,  therefore,  go  to  a  much  greater  extent 
without  destroying  life  than  is  possible  in  the  case  of  fever,  for  the  mass 
of  the  blood  and  every  tissue  in  the  body  is  more  or  less  affected,  while 
the  action  of  some  of  the  most  sensitive  organs  is  seriously  deranged 
and  the  organs  themselves  damaged.  Not  unfrequently  the  brain  and 
some  parts  of  the  nervous  system  seem  to  be  poisoned  by  the  altered 
blood.  A  huge  abscess  containing  pints  of  pus  may  be  formed  in  the 
course  of  a  fever  and  the  patient  nevertheless  get  perfectly  well,  if  only 
his  strength  can  be  sufficiently  supported  and  the  case  be  well  nursed 
and  judiciously  managed.  Anything  like  general  suppuration  of  all  the 
tissues  of  the  body  is  impossible  in  fever,  because  death  would  take 
place  long  before  such  an  event  could  occur. 

The  formation  of  pus,  and  the  manner  in  which  the  pus-corpuscles 
move  and  grow  and  multiply,  have  been  already  referred  to  on  p.  223. 

Of  the  Passage  of  Blood  and  Living  Particles  through  the  Walls  of 
Capillary  Vessels. — Diapedesis. — I  have  now  to  say  a  few  words  about 
certain  other  phenomena  of  inflammation.  When  ordinary  inflammation 
takes  place  in  a  part,  the  vessels,  as  I  have  already  said,  are  more  or  less 
distended  with  blood,  and  as  the  walls  of  these  capillary  vessels  are 
stretched  and  rendered  thinner  by  distention,  fluid  will  more  readily 
transude  through  them  than  when  they  are  in  their  usual  medium  state 
of  tension.  Suppose  this  outline  (chalk  diagram)  to  represent  the  area 
of  a  section  of  a  capillary  vessel  in  the  ordinary  state,  neither  contracted 
nor  stretched.  This  larger  circle  with  thinner  outline  (diagram)  may 
stand  for  the  same  capillary  vessel,  with  its  walls  much  thinner  and  its 


THE   PASSAGE    OF  PARTICLES  241 

calibre  greatly  increased,  as  in  the  state  of  congestion,  which  gradually 
passes  into  inflammation.  Now,  it  is  obvious  that,  if  the  walls  of  this 
capillary  are  to  be  so  stretched  as  to  form  a  tube  as  much  more  capacious 
than  the  vessel  in  the  ordinary  state,  as  would  be  the  tube  of  which  this 
circle  is  the  limit,  than  that  indicated  by  the  last  outline,  great  thinning 
of  the  walls  must  take  place.  Whenever  capillary  vessels  are  distended 
with  blood,  there  must  be  increased  tenuity  of  their  walls.  The  greater 
the  diameter  of  the  vessel  the  thinner  will  be  its  walls,  and  the  thinner 
the  walls  the  more  readily  will  fluid  permeate  them.  Now,  in  Inflam- 
mation and  Fever,  fluid,  and  often  not  only  fluid,  transudes  from  the 
blood  through  the  walls  of  the  capillaries  of  the  affected  parts  into  the 
tissues  around  the  blood-vessels. 

The  material  which  is  poured  out  has  long  been  called  Exudation,  and 
this  material  varies  somewhat  in  character  and  composition  in  different 
cases.  Certain  changes  taking  place  in  the  blood  itself  may  cause  the 
fluid  to  become  more  permeable  than  the  ordinary  fluid  portion  (liquor 
sanguinis)  of  healthy  blood.  In  many  forms  of  disease  the  quantity  of 
matter  dissolved  in  the  fluid  which  permeates  the  vascular  walls  is'greatly 
increased,  and  probably  the  fluid  itself  is  otherwise  changed.  But  you 
must  bear  in  mind  that,  beside  the  fluid  which  transudes  through  the 
capillary  vessels  in  inflammation  and  fever,  multitudes  of  excessively 
minute  and  very  soft  particles  also  traverse  the  capillary  wall.  Of  these 
the  great  majority  are  less  than  the  one  hundred-thousandth  of  an  inch 
in  diameter,  but  some  are  very  much  larger  than  this.  Indeed,  particles 
as  large  as  a  red  blood-corpuscle  may  find  their  way  through  the  capil- 
lary wall  without  causing  any  rupture  or  permanent  damage  to  the  vessel, 
and  through  openings  which  it  is  not  easy  to  demonstrate.  Of  this, 
instances  have  long  been  known  in  the  case  of  what  has  been  correctly 
termed  capillary  haemorrhage.  After  this  haemorrhage  has  taken  place, 
the  stretched  and  distended  vessels  may  return  to  their  ordinary  con- 
dition without  any  deterioration  of  the  structure  occurring  in  the  walls 
which  have  been  stretched.  Such  phenomena  occur  in  every  case  of 
pneumonia. 

You  will  naturally  ask  how  large  particles  like  the  red  blood-corpuscles 
pass  through  the  walls  of  vessels  in  which  no  fissures  or  openings  can  be 
discerned.  When  we  study  the  changes  taking  place  during  develop- 
ment, we  learn  that  the  walls  of  the  capillary  vessels  are,  as  it  were,  laid 
.down  in  such  manner  that  the  tissue  of  which  they  are  composed,  though 
exhibiting  no 'definite  indication  of  actual  fibres,  will  tear  much  more 
readily  in  the  longitudinal  than  in  the  transverse  direction.  Whenever 
the  capillaries  are  distended  by  the  accumulation  of  blood,  and  their 
walls  stretched  by  lateral  pressure,  the  fibre  net-work,  of  which  they  may 
be  supposed  to  consist,  would  have  its  meshes  considerably  widened  in 
such  a  way  that  longitudinal  rents  or  fissures  would  result,  which  would 
be  large  enough  to  permit  the  passage  of  more  than  one  red  blood-cor- 

21  Q 


242  THROUGH   THE    WALLS   OF    VESSELS. 

puscle  at  a  time  through  them.  The  distending  force  ceasing,  the  elastic 
tissue  of  the  capillary  wall  would  react,  and  the  vessel  gradually  return 
to  its  ordinary  size,  the  rent  slowly  closing  up. 

We  can,  therefore,  readily  imagine  that  a  body  as  large  as  a  blood- 
corpuscle  would  easily  escape  sideways  through  one  of  these  fissures  and 
pass  amongst  the  tissues  outside  the  vessel.  Such  escape  of  blood-cor- 
puscles, a  few  at  a  time,  takes  place  from  the  capillaries  of  the  walls  of 
the  air-cells  of  the  lungs  in  every  case  of  ordinary  inflammation  of  the 
lung  tissue,  or  Pneumonia.  In  cases,  however,  in  which  blood  extrava- 
sates  to  any  great  extent,  as  where  blood  escapes  from  a  surface  in  drops, 
a  free  tearing,  or  other  solution  of  continuity,  of  the  walls  of  the  vessels 
undoubtedly  occurs.  Even  where  violent  haemorrhage  has  taken  place 
from  vessels  of  considerable  dimensions,  it  is  often  most  difficult  to 
demonstrate  the  opening.  You  need  not,  therefore,  be  surprised  to  learn 
that  it  is  almost  impossible  to  expose  the  actual  holes,  rents,  or  fissures 
in  the  walls  of  capillary  vessels  which  have  allowed  the  exit  of  a  few 
blood-corpuscles.  There  are  cases  in  which  haemorrhage  occurs  from  a 
vast  tract  of  capillary  vessels,  as  for  example,  of  the  mucous  membrane 
of  the  small  intestine,  and  yet  the  fissures  or  rents  cannot  be  detected, 
though  several  pints  of  blood  may  have  been  lost  in  the  course  of  half 
an  hour,  in  consequence  of  capillary  hemorrhage.  This  may  cause  faint- 
ness  and  death.  In  such  cases  of  fatal  capillary  haemorrhage,  no  doubt, 
degenerative  changes  have  been  taking  place  in  the  walls  of  the  capillary 
vessels  involved,  during  a  considerable  period  of  time  previous  to  the 
occurrence  of  the  haemorrhage.  When  one  comes  to  examine  the  mucous 
membrane  after  death,  the  whole  of  the  surface  is  found  suffused,  and 
the  tissues,  so  to  say,  infiltrated  with  blood  which  has  issued  from  mil- 
lions and  millions  of  capillaries,  distributed  over  perhaps  as  much  as  six 
feet  of  intestine. 

I  have  seen  several  instances  of  death  from  almost  sudden  and  profuse 
capillary  haemorrhage  from  the  mucous  membrane,  extending  over  many 
feet  of  the  small  intestine,  consequent  upon  slow  morbid  changes  pro- 
ceeding in  the  liver  and  resulting  in  the  condition  known  as  cirrhosis. 
In  the  course  of  this  disease  the  circulation  through  the  liver  becomes 
greatly  impeded,  and  in  consequence  congestion  of  the  mucous  mem- 
brane of  the  intestines  ensues,  and  frequent  slight  attacks  of  bleeding 
occur,  which  may  at  last  end  in  extensive  and  fatal  haemorrhage.  If  you 
were  to  inject  the  vessels  in  such  a  case,  the  injection  would  ooze  from 
multitudes  of  minute  openings,  but  no  large  aperture  would  be  discovered 
in  any  large  or  small  vein  or  artery.  The  case  is  very  different  where  a 
large  vessel  is  opened  in  the  process  of  ulceration,  as  frequently  occurs 
in  the  course  of  ulcer  of  the  stomach  and  in  phthisis,  or  as  sometimes 
happens  in  aneurism. 

There  are  certain  forms  of  capillary  bleeding  or  haemorrhage  which 
are  very  common,  and  not  indicative  of  any  actual  disease,  and  which 


COHNHEIATS  RESEARCHES.  24$ 

may  fairly  be  regarded  as  slight  ailments.  Bleeding  from  the  mucous 
membrane  of  the  nose  is  one  of  these.  Some  children  frequently  suffer 
from  this  affection,  and  in  certain  instances  relief  to  headache  or  to  a 
sensation  of  fulness  in  the  head  is  afforded  by  the  slight  loss  of  blood 
which  occurs.  Haemorrhage  of  the  same  kind  may  take  place  from  the 
back  of  the  throat,  from  the  gums,  from  the  stomach,  and  even  from  the 
lungs.  Occasionally  bleeding  takes  place  from  the  rectum,  without  pro- 
ducing more  than  temporary  derangement,  though,  of  course,  it  causes 
alarm  to  the  patient  and  his  friends. 

You  must  be  very  careful  about  giving  a  too  positive  opinion  concern- 
ing the  exact  nature  of  many  of  such  cases,  for  bleeding  from  one  or 
other  of  the  surfaces  above  mentioned  may  be  a  grave  matter,  and  per- 
haps the  first  indication  of  serious  disease.  On  the  other  hand,  even 
several  teaspoonfuls  of  blood  may  escape  from  capillary  vessels  without 
the  general  health  being  in  any  way  deranged.  After  tension  has  been 
relieved  by'this  haemorrhage,  the  vessels  return  to  their  former  state  and 
the  blood  circulates  in  them  as  before. 

In  cases  of  haemorrhage  from  the  mucous  membrane  of  the  nose,  I 
believe  that  the  capillaries  become  much  congested,  and  that  actual 
longitudinal  rents  or  fissures  are  made  through  which  blood  escapes.  If 
the  attacks  are  frequent  and  severe  and  the  patient's  strength  fails,  it 
may  be  necessary  to  adopt  remedial  measures  even  in  a  case  of  what 
appears  to  be  ordinary  bleeding  from  the  nose.  Perfect  rest  in  the  half- 
recumbent  posture,  the  application  of  cold  to  the  nose  externally,  suck- 
ing small  pieces  of  ice,  are  usually  effectual,  but  it  may  be  necessary  to 
use  styptics  or  "plug  the  nostrils"  in  severe  cases.  This,  however,  is 
not  the  place  to  discuss  the  treatment  requisite  in  cases  of  such  gravity. 
It  should,  however,  be  borne  in  mind  that  bleeding  not  depending  upon 
actual  disease  may  take  place  from  many  other  organs  and  surfaces  as 
well  as  from  the  mucous  membrane  of  the  nose. 

Haemorrhage  from  minute  vessels  used  to  be  spoken  of -as  haemorrhage 
by  exhalation  ;  and  the  older  observers  believed  the  escape  of  blood  from 
the  vessels  occurred  in  some  mysterious  manner  not  to  be  adequately  ex- 
plained. They  seemed  to  think  that  the  blood  passed  through  the  walls 
of  vessels  in  some  strange  and  inscrutable  way.  By  the  aid  of  recent  in- 
vestigations we  can  form  a  clear  idea  of  the  manner  in  which  the  haemor- 
rhage through  the  walls  of  the  capillaries  may  occur  without  actual  rup- 
ture. The  phenomenon  is  of  great  interest,  and  we  may  conveniently 
consider  under  the  same  head  a  process  which  has  been  regarded  by  many 
observers  as  essential  to  more  than  one  general  pathological  change,  and 
which  has  been  spoken  of  as  Diapedesis. 

It  was  proved  experimentally  by  Cohnheim,  of  Berlin,  that  colorless 
blood-corpuscles  might  pass  from  the  cavity  of  the  peritoneum  into  the 
vascular  system,  and  that  in  the  case  of  the  membrane  of  the  frog's  foot 
and  other  tissues  when  in  a  state  of  inflammation,  colorless  blood-corpus- 


244  MINUTE  BIOPLASTS. 

cles  made  their  way  through  the  capillary  walls,  though  no  openings  could 
be  seen  and  the  capillaries  themselves  were  not  unduly  distended.  Cohn- 
heim  maintained  that  this  migration  of  colorless  blood-corpuscles  was  an 
ordinary  phenomenon;  that  it  was  common,  and  constantly  took  place, 
to  a  great  extent,  in  every  case  of  inflammation.  Nay,  he  went  so  far 
as  to  insist  that  pus  itself  consisted  of  colorless  blood-corpuscles  which 
had  made  their  way  out  of  the  vessels.  Of  course  it  occurred  to  many 
that  the  last  proposition  was  rather  difficult  to  accept,  for  the  number 
of  pus-corpuscles  in  an  ordinary  abscess  formed  in  the  course  of  the 
twenty-four  hours  is  so  great,  that  had  every  colorless  blood-corpuscle 
in  the  body  made  its  way  into  the  abscess  a  mere  modicum  of  the  total 
quantity  of  pus  present  would  be  thus  accounted  for.  The  pus-corpus- 
cles in  a  small  abscess,  or  on  the  surface  of  an  inflamed  mucous  mem- 
brane, outnumber  by  many  times  the  whole  of  the  colorless  blood- 
corpuscles  in  the  organism.  Many  observers  in  this  country,  however, 
advocated  the  above  view,  and  it  has  in  consequence  formed  a  cardinal 
doctrine  of  more  than  one  school  of  pathology.  Of  those  who  profess 
to  have  seen  the  phenomenon  in  question,  not  a  few  will  tell  you  that 
it  is  easily  demonstrated  and  occurs  constantly.  He  who  proceeds  to 
study  the  matter  for  himself  will,  I  think,  find  that  only  very  occasion- 
ally can  he  feel  at  all  sure  that  a  colorless  blood-corpuscle  has  actually 
passed  through  the  vascular  walls.  The  careful  observer  will  not  unfre- 
quently  find  that  a  corpuscle  which  seems  to  pass  through  the  walls  of  a 
vessel  does  not  really  do  so,  and  is,  in  fact,  either  in  front  of  the  capil- 
lary or  behind  it,  and  has  not  come  out  of  the  vessel  at  all.  There  is, 
however,  no  doubt  that  this  migration  of  colorless  blood -corpuscles  does 
occur,  but  I  believe  it  to  be  an  exceptional,  rather  than  a  common  or 
ordinary,  phenomenon,  while  I  feel  sure  that,  in  many  cases,  the  proc- 
ess of  inflammation  may  run  its  course  entirely  without  the  escape  of  a 
single  blood-corpuscle. 

The  corpuscles  found  outside  the  capillaries  in  great  numbers  in  cases 
of  inflammation,  are  produced  not  by  the  passage  of  colorless  corpuscles 
from  the  blood,  but  by  the  growth  of  very  minute  particles  which  have 
escaped  with  the  transuded  fluid.  These  particles  do  not  consist  of  col- 
orless blood-corpuscles,  which,  as  such,  have  traversed  the  walls  as  has 
been  supposed.  So  far  from  having  been  colored  blood-corpuscles,  it  is 
doubtful  whether  at  any  time  one  of  them  ever  circulated  in  the  bloc.l 
as  such.  What,  then,  are  these  bodies,  and  how  did  they  attain  the 
position  in  which  we  find  them? 

Some  years  before  the  above  views  were  published  and  popularized  in 
this  country,  I  had  described  another  process  of  migration,  or  rather 
pouring  out,  from  the  blood,  suspended  in  liquor  sanguinis,  of  minute 
particles  of  living  matter  or  bioplasm,  which  no  doubt  play  a  very  im- 
portant part -in  the  complex  phenomenon  of  inflammation.  I  showed 
that,  if  a  very  thin  layer  of  healthy  blood  was  examined  by  a  high  mag- 


'     SPONTANEOUS  MOVEMENTS  24$ 

nifying  power,  a  n  amber  of  corpuscles,  infinitely  smaller  than  either  red 
or  colorless  corpuscles,  were  to  be  detected  ;  and  not  only  so,  but  I  proved 
that  these  minute  corpuscles,  varying  from  the  one  hundred-thousandth 
to  the  one  ten-thousandth  of  an  inch  in  diameter,  and  probably  corpus- 
cles still  more  minute,  consisted  of  bioplasm,  or  living  matter.  The. 
blood  of  man  and  the  higher  animals,  while  circulating  in  the  living 
body,  ought  to  be  regarded  as  a  fluid  holding  in  suspension  countless 
multitudes  of  minute  particles  of  living  matter  which,  at  death,  undergo 
a  great  change,  and  become  converted  into  several  different  substances, 
among  the  most  important  of  which  is  the  matter  we  call  fibrin.  Similar 
minute  particles  of  living  matter  are  held  in  suspension  in  the  circulating 
and  nutrient  fluids  of  every  living  organism,  and  are  present  even  in  the 
nutrient  fluids  of  plants. 

In  the  large  cells  of  Vallisneria  spiralis,  which  you  may  easily  grow  in 
a  glass  jar  in  your  sitting-room,  you  may  see  the  rotation  of  the  so-called 
"cell-contents."  The  most  important  of  these  contents  being  the  ap- 
parently clear  homogeneous  fluid  which  passes  round  and  round  the  cell, 
as  long  as  the  very  minute  particles  of  bioplasm  suspended  in  it,  but  to 
be  demonstrated  only  by  the  aid  of  very  high  powers,  continue  alive. 
No  one  has  succeeded  in  accounting  for  these  movements  by  physical 
and  chemical  change,  though  many  have  attempted  to  do  so.  Many 
more  have  affirmed  that  it  can  be  so  explained,  and  with  the  confidence 
and  satisfaction  characteristic  of  the  new  philosophy,  have  affirmed  that, 
even  if  the  explanation  they  have  given  is  not  quite  adequate  and  satis- 
factory at  this  time,  it  will  be  found  to  be  so  at  some  future  period. 

The  power  of  moving  resides  in  the  minute  particles  themselves.  As 
long  as  the  matter  of  which  these  consist  lives  the  particles  may  move, 
but  when  it  dies  the  moving  power  is  completely  lost.  This  remarkable 
spontaneous  movement,  which  cannot  be  explained,  which  we  may  see  in 
the  pus-corpuscles,  in  the  colorless  blood-corpuscles,  and  in  other  forms 
of  bioplasm  belonging  to  man,  to  animals,  and  to  plants,  has  been 
attributed  to  certain  reactions  between  the  particles  themselves  and 
things  in  their  environment,  but  if  you  will  only  look  for  yourselves  and 
ponder  over  what  you  observe,  you  will  soon  be  convinced  of  the  incor- 
rectness of  the  hypothesis.  At  no  period  of  history  have  such  ridiculous 
statements  been  made  concerning  the  nature  and  actions  of  living  things 
as  in  our  own  time.  So  far  from  being  in  advance  of  old  doctrines,  the 
ancients  would  have  ridiculed  much  that  now  passes  for  philosophy.  It 
must  be  admitted  that  the  most  nonsensical  views  concerning  many 
things  have  been  received  as  true  because  they  have  been  repeatedly 
urged  in  the  strongest  language.  When  people  hear,  an  assertion  re- 
peated again  and  again  they  think  there  must  be  "something  in  it."  So 
they  believe  it,  or  act  upon  it,  as  the  case  may  be.  The  confidence  with 
which  physical  explanations  of  purely  vital  phenomena  are  insisted  upon 
is  most  extraordinary.  On  the  one  side  there  is  astounding  audacity 
21* 


246  OF  LIVING   MATTER. 

and  arrogance,  on  the  other  meek  acquiesence,  and  an  almost  incredible 
credulity.  Some  teachers  do  not  hesitate  to  tell  the  public  that  they  know 
many  things  which  have  never  been  and  cannot  be  proved.  They  are, 
we 'are  assured,  peculiarly  strong  and  "  privileged  "  to  prophecy,  and  to 
do  other  out  of  the  way  things.  Such  persons  affirm  that  they  discern 
all  sorts  of  wonderful  things,  but  they  cannot  tell  us  how  to  discern,  nor 
do  they  explain  by  what  means  they  have  been  able  to  discern.  They 
are  "gifted  spirits,"  and  do  not  belong  to  the  class  of  ordinary  mortals. 
Some  prophetic  philosophers,  without  having  earnestly  studied  the  phe- 
nomena of  any  living  thing  in  nature,  nay,  without  being  even  practi- 
cally skilled  in  the  ordinary  methods  of  investigating  the  structure  of 
any  living  thing,  dare  to  wildly  assault  the  whole  world  of  life,  and  reck- 
lessly declare  that  all  living  things  are  produced  and  built  up  and  worked 
according  to  the  very  same  principles  and  laws  by  which  the  non-living 
world  is  fettered  and  confined  in  eternal  helplessness. 

Let  me  persuade  you  to  observe  what  happens  as  the  simplest  of  liv- 
ing things  grows.  Take,  for  instance,  ordinary  mildew,  wh*ich  can  be 
obtained  easily  enough,  or  which  each  can  grow  for  himself,  for  its  germs 
are  always  present  in  the  air.  You  may  grow  it  in  a  little  acid  urine  if 
you  like.  By  carefully  watching  it,  you  will  be  convinced  that  it  grows 
by  taking  up  nutrient  matter,  which  is  not  deposited  upon  its  surface 
but  taken  into  its  very  substance,  where  it  becomes  converted  into  living 
matter,  from  every  particle  of  which  new  particles  may  result.  Ask  the 
physicist  to  explain,  if  he  can  do  so  by  any  physical  laws,  the  phe- 
nomena which  have  occurred  while  the  organism  has  been  under  your 
observation. 

Up  to  this  time,  instead  of  telling  us  what  is  going  on,  instead  of 
describing  by  what  means  matter  is  changed  in  composition  and  acquires 
new  properties  whenever  it  is  caused  to  assume  the  living  state,  confident 
physicists  assert,  and  with  an  air  of  superiority,  what  according  to  their 
powers  of  prevision  is  certainly  to  be  achieved  by  physicists  in  the  far- 
off  future.  Perhaps  the  materialist  gifted  with  prophetic  powers  enlarges 
on  the  subject  of  ch'emical  affinity  and  its  possibilities  in  the  future,  per- 
haps he  will  tell  you  about  properties  and  attractions,  tendencies,  molecu- 
lar forces,  potentialities,  and  evolutions  and  laws,  and  discoveries  con- 
cerning things  that  may  be,  or  according  to  him  must  be,  and  which  he, 
but  no  one  else,  can  discern  in  his  imagination.  He  will  not,  hoAvever, 
tell  you  what  happens  whenever  lifeless  matter  is  made  to  live,  or  when 
I'.ving  matter  dies.  All  the  assertions  made  during  the  last  ten  years  or 
more  on  the  identity  of  vital  and  physical  properties  have  but  retarded 
real  advance  in  biological  science.  No  adequate  explanation  as  regards 
the  nature  of  the  change  from  non-living  to  living,  and  from  living  to 
dead,  has  been  discovered  in  the  past.  Nothing  definite  is  known  to 
the  physicist  at  the  present  time,  but  what  is  not  discovered  by  him  no~v 
is,  he  asserts,  to  be  rendered  evident  by  his  successors  in  the  future, — 


CHANGES  IN  BIOPLASM.  247 

that  future  which  is  now  very  far  off,  and  which  ever  gets  dimmer  and 
more  remote  as  time  passes.  The  truth  is  the  materialist  view  of  things 
is  a  mere  absurdity,  based  on  fancies  and  dicta  instead  of  on  facts. 

The  vital  phenomena  observed  in  the  case  of  the  mildew  or  any  other 
simple  organism,  closely  resemble  those  which  are  observed  in  the  case 
of  living  particles  belonging  to  man  and  the  higher  animals,  both  in 
health  and  disease,  and  can  be  accounted  for  only  by  attributing  them 
to  the  influence  of  a  peculiar  power  or  agency  associated  with  the  matter 
while  it  is  alive,  and  which  is  absolutely  distinct  from  any  of  the  known 
properties  or  forces  of  ordinary  matter. 

The  minute  particles  of  bioplasm  or  living  matter  which  pass  through 
the  walls  of  the  capillary  vessels  in  cases  of  ordinary  inflammation  soon 
begin  to  undergo  alteration.  As  long  as  they  were  being  rapidly  moved 
about  in  the  blood-stream  these  particles  would  undergo  little  or  no  ac- 
tive change ;  but  as  soon  as  they  become  still  and  quiescent,  by  their 
own  inherent  power  of  movement  they  begin  to  make  their  way  through 
the  walls  of  the  vessels  (p.  240),  and  soon  take  up  and  appropriate  the 
nutrient  material  which  surrounds  them  in  great  quantities.  While  in 
the  blood,  probably  in  those  organs  where  the  circulation  of  the  blood 
goes  on  very  slowly,  these  minute  particles  grow  and  slowly  undergo 
conversion  into  the  bodies  known  as  the  colorless  blood-corpuscles. 
When  outside  the  vessels,  as  in  inflammation,  the  particles  grow  more 
quickly,  and  soon  assume  the  form  of  the  colorless  corpuscles  which  we 
see  in  such  immense  numbers  in  the  interstices  of  various  tissues  and  just 
outside  the  walls  of  the  vessels  in  inflammation. 

i.  Under  certain  circumstances  the  bioplasts  in  question  soon  die,  and 
the  products  resulting  from  their  death  are  quickly  re-absorbed.  2.  Under 
other  conditions  they  develop  a  delicate  fibrous  material.  3.  If  supplied 
with  plenty  of  pabulum  they  may  continue  to  grow  and  multiply  very 
rapidly  until  the  form  of  living  matter  known  as  pus  results.  Pus-cor- 
puscles are  particles  of  living  matter  or  bioplasm,  which  have  been  devel- 
oped by  direct  descent,  but  with  modification  in  power,  from  the  minute 
living  particles  under  consideration,  or  more  directly  from  colorless  blood- 
corpuscles,  or  from  the  bioplasm  of  some  tissue.  From  such  particles 
of  bioplasm  every  form  of  adventitious  fibrous  tissue  which  we  find  out- 
side the  walls  of  the  capillaries  and  in  the  interstices  of  the  tissues,  in 
various  forms  both  of  acute  and  chronic  inflammation,  is  produced.  The 
delicate  fibrous  tissue  at  first  formed  loses  water,  contracts,  and  gradually 
becomes  condensed.  The  "thickening"  and  condensation  which  you 
often  meet  with  in  tissues  which  have  been  inflamed  is  thus  brought 
about. 

As  I  have  already  remarked,  the  minute  particles  of  living  matter,  or 
bioplasm,  outside  the  walls  of  the  capillaries  may  also  grow  and  multiply 
until  multitudes  of  "  pus-corpuscles  "  result.  Even  at  this  time  the  fact 
that  pus-corpuscles  grow  and  multiply  of  themselves  by  the  formation  of 


248  SLIGHT  INFLAMMATION. 

little  offsets,  outgrowths,  or  diverticula,  which'  are  from  time  to  time 
detached,  is  not  generally  recognized.  You  may  remember,  in  a  former 
lecture,  I  described  how  the  bioplasm  of  a  cell  might  increase  in  size, 
and  might  give  off  diverticula,  which  being  detached,  form  separate 
portions  of  bioplasm,  each  of  which  may  grow  and  give  off  more  proc- 
esses, until  by  the  growth  and  multiplication  of  a  few  particles  millions 
of  the  masses  of  bioplasm  known  as  pus-corpuscles  are  formed,  every  one 
of  which  may  be  regarded  as  the  descendant  of  the  bioplasm  or  nucleus 
of  an  epithelial  cell.  The  pus-corpuscles  cannot,  therefore,  be  looked 
upon  as  an  individual  colorless  blood-corpuscle,  which  has  simply  mi- 
grated from  the  blood  by  traversing  the  walls  of  the  vessel. 

The  idea  that  the  formation  of  pus  is  in  any  way  dependent  upon  bac- 
teria or  other  forms  of  so-called  micro-organisms  is  negatived  by  what 
maybe  easily  seen  in  the  production  of  pus-corpuscles  in  epithelial  cells. 
The  growth  of  the  bioplasm  and  its  division  and  subdivision  under  con- 
ditions which  involve  increased  nutrition  will  convince  any  one  who 
observes  the  phenomenon  how  pus  is  produced  in  epithelium ;  and  as 
exactly  corresponding  facts  are  to  be  demonstrated  by  the  examination 
of  bioplasm  in  other  tissues,  cartilage,  fibrous  tissue,  muscle,  nerve,  etc., 
when  exposed  to  the  influence  of  an  unusual  supply  of  pabulum,  no  room 
is  left  for  doubt  as  to  the  exact  nature  of  the  pathological  process  of  pus 
production.  I  cannot  agree  with  my  colleague,  Professor  Lister,  in  con- 
sidering that  putrefactive  materials  maybe  the  cause  of  suppuration,  nor 
can  I  admit  that  this  process  can  be  properly  attributed  to  chemical  sub- 
stances or  to  nervous  disturbance.  A  state  of  things  may  be  brought 
about  by  these  which  may  indirectly  occasion  the  free  distribution  of 
nutrient  matter  to  bioplasm  to  which  the  production  of  pus  is  directly 
and  solely  attributable  in  all  cases. 

SOME  COMMON  FORMS  OF  SLIGHT  INFLAMMATION  AND  OF  THEIR 

TREATMENT. 

We  will  now  endeavor  to  determine  what  are  the  essential  changes 
which  occur  in  epithelium  and  in  some  other  tissue  elements  in  ordinary 
slight  inflammations.  These  changes  do  not  necessarily  lead  to  any 
structural  alterations  ;  but  if  the  inflammatory  process  continues  for  a 
certain  period  of  time,  it  may  be  followed  by  tissue  degeneration  and 
other  pathological  phenomena,  from  which  return  to  the  normal  state, 
complete  recovery,  cannot  be  looked  for.  Not  a  few  of  the  slight  in- 
flammations are  superficial,  involving  a  very  thin  layer  of  the  surface 
tissue  only,  and  although  most  of  them  are  by  no  means  serious,  some 
are  very  troublesome  and  many  excessively  painful.  It  is  desirable, 
therefore,  not  only  that  you  should  know  how  to  detect  and  distinguish 
them,  but  you  ought  to  be  fully  conversant  with  the  exact  nature  of  the 
minute  changes  taking  place  and  the  methods  by  which  a  return  to  the 
normal  state  may  be  effected. 


INFLAMMATORY  CHANGE.  249 

The  treatment  of  some  of  the  inflammations  in  question  has  been 
already  considered,  but  it  seems  to  me  very  important  that  I  should  do 
my  best  to  press  upon  your  consideration  the  character  of  the  changes 
effected  by  simple  remedies  in  the  vital  actions  which  are  proceeding  in 
the  inflamed  tissue,  the  effects  pf  some  of  which  have  been  rendered 
evident  to  us  by  careful  microscopical  research.  He  will  be  most  suc- 
cessful, in  the  management  of  the  disease  who  most  nearly  succeeds  in 
picturing  to  himself  the  wonderful  changes  which  proceed  in  such  mar- 
vellous minuteness  and  detail,  and  which  can  only  be  revealed  to  those 
who  have  long  and  earnestly  studied,  and  have  taken  full  advantage  of, 
the  elaborate  means  of  minute  investigation  now  at  their  disposal. 

The  mucous  membrane  of  the  nose  and  its  many  passages,  as  has  been 
already  stated  (p.  214),  is  very  liable  to  slight  inflammation.  In  the 
changes  which  occur  during  an  ordinary  cold  we  have  an  illustration  of 
the  very  gradual  passage  of  physiological  into  pathological  actions.  There 
is  a  particular  point  in  these  changes  when  it  would  be  impossible  to 
decide  whether  it  would  be  more  correct  to  say  that  the  membrane  still 
remained  in  a  healthy  state  or  had  just  passed  from  this  into  a  morbid 
condition.  The  difference  between  certain  normal  and  inflammatory 
states  unquestionably  depends  only  upon  an  exaggeration  of  the  activity 
with  which  normal  changes  are  performed.  In  suppuration  there  is  too 
much  vital  action,  too  much  growth,  and  too  rapid  multiplication  of 
living  particles. 

It  is  by  the  careful  study  of  inflammatory  changes  only  moderate  in 
degree  that  we  shall  be  able  to  answer  the  question  why  in  one  case  the 
healing,  and  in  another,  apparently  similar  in  all  general  respects,  the 
opposite  and  destructive  process,  occurs.  A  slight  wound  suppurates 
which  we  desire  should  heal ;  an  ulcer  forms  and  increases  in  spite  of  all 
our  efforts  to  stop  its  ravages.  The  observations  made  on  p.  254.  bear 
upon  this  most  important  question  ;  and  while  one  set  of  inquirers  would 
attribute  the  want  of  repair  to  some  derangement  of  the  nervous  system, 
another  set  to  some  chemical  poison  in  the  air,  another  to  the  presence 
of  bacteria  of  a  malignant  type,  I  would  refer  it  solely  to  the  state  of  the 
patient's  blood — to  the  presence  in  the  circulating  fluid  of  an  abnormal 
quantity  of  material  easily  appropriated  by  low  forms  of  bioplasm  or 
living  matter,  and  to  the  presence  of  multitudes  of  minute  particles  of 
these — of  bioplasm  particles,  which,  passing  through  the  capillary  walls, 
grow  and  multiply,  and  actually  prevent  the  slower  changes  which  ordi- 
narily result  in  the  formation  of  formed  material,  and  which  constitute 
an  essential  part  of  the  healing  process.  If  the  matter  upon  which  these 
particles  live  can  be  removed  from  the  blood,  we  shall  stop  the  growth 
and  multiplication  of  the  bioplasm  particles  and  cause  their  death. 
Hence  in  cases  in  which  the  patient's  strength  is  good,  free  purgation 
favors  the  healing  process,  and  in  the  case  of  those  who  suffer  from 
prostration,  alcohol  in  the  blood,  and  the  application  of  alcohol,  and 


2$O  FORMATION  OF  MUCUS. 

things  which  act  like  alcohol  to  the  wound,  acts  in  the  same  beneficial 
manner;  for  this  substance  interferes  with  the  growth  of  living  matter, 
and  alters  the  pabulum  in  such  a  manner  as  to  render  it  unfit  for  the 
nutrition  of  the  living  particles. 

Formation  of  Mucus. — Mucus,  as  yo«  know,  is  formed  in  small  quan- 
tity in  the  follicles  and  glands  in  connection  with  the  mucous  membrane 
of  the  nose,  even  in  perfect  health.  When  we  suffer  from  a  common 
"cold  in  the  head,"  these  particles  of  bioplasm  which  take  part  in  the- 
formation  of  the  tenacious  mucus  around  them  grow  and  multiply  more 
quickly  than  they  do  in  the  perfectly  healthy  state.  The  viscid  material 
(mucus)  formed  by  them  is  in  greater  proportion,  softer  in  consistence, 
perhaps  disintegrated  and  broken  down,  or  actually  decomposed,  and  in 
it  bacteria  and  low  forms  of  life  find  materials  favorable  for  their  devel- 
opment and  eminently  suitable  for  their  nutrition. 

Mucus-Corpuscle.  I  have  many  times  spoken  of  the  bioplasm  which 
constitutes  the  so-called  Mucus-corpuscle,  but  I  have  not  told  you  how 
you  should  proceed  to  observe  the  wonderful  vital  movements  which 
occur  during  its  life,  and  especially  at  the  commencement  of  a  slight 
cold,  when  the  activity  of  the  movement  is  considerably  increased. 
Having  obtained,  by  coughing  or  sneezing,  a  small  piece  of  the  trans- 
parent mucus,  about  the  size  of  a  pin's  head,  place  it  on  an  ordinary 
microscope  plate-glass  slide.  Next  cover  it  with  a  piece  of  the  thinnest 
covering-glass  you  can  obtain,  without  adding  water  or  any  other  sub- 
stance. Gently  press  down  the  thin  glass  cover  with  the  aid  of  a  pin  or 
needle,  and  place  the  slide  under  the  microscope,  using  first  of  all  a 
quarter  of  an  inch  object-glass,  and  then  a  twelfth  or  higher  power,  if 
you  are  fortunate  enough  to  possess  one.  If  not,  you  can  gain  the  req- 
uisite degree  of  amplifying  power  in  another  way,  and  at  the  cost  of  a 
shilling  or  two.  A  piece  of  brass  tubing,  of  the  same  diameter  as  that 
of  the  tube  of  the  microscope,  and  arranged  to  carry  the  eye-piece,  is 
fitted  to  it,  sliding  in  just  as  the  eye-piece  does.  The  total  length  of 
the  tube,  to  one  end  of  which  the  object-glass,  and  to  the  other  the  eye- 
piece, is  attached,  is  in  this  way  increased  to  about  eighteen  inches. 
The  intensity  of  the  illumination  being  somewhat  increased,  you  will 
find  the  little  particles  of  mucus  so  highly  magnified  that  you  will  be 
able  to  see  the  slightest  changes  which  take  place  in  their  form  and  con- 
tour from  moment  to  moment. 

The  minute  oval  particles  in  the  thin  layer  of  transparent  mucus,  and 
which 'consist  of  living  matter  or  bioplasm,  may  be  said  to  represent, 
and  indeed  correspond  to,  the  "  nucleus  "  of  an  ordinary  epithelial  cell, 
while  the  mucus — that  viscid  material  which  surrounds  them — corresponds 
to  the  wall  of  the  cell.  If  the  epithelium  of  other  mucous  membranes 
grows  unusually  fast,  a  material  which  not  only  corresponds  to,  but  re- 
sembles, mucus  will  be  formed. 

If  you  select  one  of  the  oval  corpuscles,  the  living  matter  of  the  mucus, 


NERVE-FIBRES   CONCERNED  2^1 

and  examine  it  intently,  you  will  soon  observe  changes  in  its  outline. 
Here  and  there  protrusions  will  occur,  portions  of  the  mass  moving  away 
from  the  remainder,  and  then  being  withdrawn  and  incorporated.  The 
movements  indeed  very  closely  resemble  those  seen  in  an  ordinary  amoeba, 
and  are  vital  movements  of  the  same  nature.  They  continue  for  a  con- 
siderable period  of  time — perhaps  for  twelve  hours,  or  longer,  if  you  can 
keep  the  mucus  in  a  moist  atmosphere,  and  so  prevent  it  from  drying  up. 
Changes  of  the  same  kind  occur  in  bioplasm  generally,  but  it  is  only 
here  and  there  that  we  are  able  to  demonstrate  them  so  satisfactorily  as 
in  the  case  of  the  living  Mucus-corpuscle,  Pus-corpuscle,  and  colorless 
Blood-corpuscle.  In  these  living  particles  any  one  can  study,  and  at 
any  time  he  desires  to  do  so,  the  vital  movements  of  bioplasm  or  living 
matter. 

In  an  inflamed  mucous  membrane,  besides  those  prominent  derange- 
ments, increased  redness  caused  by  congestion  of  the  capillaries,  and  in- 
creased dryness  consequent  upon  the  defective  pouring  out  of  the  fluid 
from  the  blood  to  take  the  place  of  that  which  has  been  quickly  removed 
from  the  surface  by  evaporation, — we  have  to  notice  important  changes 
in  connection  with  the  action  of  the  nerves.  Every  one  who  has  had  a 
cold  knows  that  the  sensation  of  the  part  is  affected.  The  mucous  mem- 
brane is  sore  and  painful,  so  that  his  attention  is  being  frequently  directed 
to  itl  He  fancies  something  is  adhering  to  it  which  requires  to  be  re- 
moved, and  is  constantly  making  efforts  to  get  rid  of  it.  In  some  cases 
a  certain  quantity  of  mucus  collects  upon  the  surface  and  dries,  in  others 
the  sensation  experienced  seems  rather  to  be  due  to  the  tissues  being  in- 
filtrated with  fluid.  Sometimes  the  mucous  membrane,  particularly  at 
the  margin  of  the  nose,  becomes  excoriated,  or  a  superficial  ulcer  may 
form.  In  the  last  case  it  will  be  found  that  the  ordinary  protective  hard- 
ened epithelial  covering  has  been  here  and  there  removed,  and  a  raw 
and  highly  sensitive  fissure  formed,  at  the  bottom  of  which  are  capillarieS 
and  nerve-fibres.  From  the  capillaries  fluid  escapes  holding  in  suspension 
numerous  minute  particles  of  bioplasm,  and  not  unfrequently  small  quan- 
tities of  blood  itself  are  poured  out.  The  pain  experienced  is  due  .to 
the  exposure  or  incomplete  exposure  of  delicate  nerve-fibres.  The  par- 
ticular nerves  affected  are  those  which  are  distributed  close  to  the  capil- 
lary vessels,  and  which  have  been  described  in  p.  228.  But  other  nerve- 
fibres  maybe  involved,  for,  as  I  have  already  mentioned,  there  are  tissues 
in  which  nerve-fibres  are  distributed,  although  no  capillaries  exist,  which 
nerve-fibres  are  concerned  in  the  pain  experienced  when  the  tissue  is  in- 
flamed. At  the  same  time  it  is  probable  that  the  nerves  in  question  be- 
long to  the  same  system  as  those  distributed  to  capillaries,  while  there 
is  no  doubt  that  the  latter  are  concerned  in  transmitting  to  us  the  im- 
pressions which  we  call  pain.  I  have  already  remarked  that  as  regards 
many  tissues  to  which  numbers  of  nerve-fibres  are  distributed,  we  are 
quite  unconscious  of  their  existence  so  long  as  the  normal  or  healthy 


252  IN  PAINFUL   SENSATIONS. 

state  lasts,  but  as  soon  as  this  gives  place  to  inflammation,  pain,  it  may 
be  of  the  most  exquisite  kind,  results.  The  nerves  concerned  being 
those  of  the  capillary  vessels  which  belong  to  that  self-regulating  system 
of  nerves  before  referred  to  (p.  232).  These  fine  nerve-fibres  become, 
as  I  have  said,  stretched  or  pressed  upon  by  the  distended  capillary  ves«- 
sels,  and- perhaps  otherwise  affected* by  the  exudation  which  takes  place. 
And  in  consequence  of  these  derangements,  this  departure  from  the 
normal  state,  as  respects  the  nerve- fibre,  and  the  bioplasm  which  is  con- 
nected with  it,  that  disturbance  of  the  nerve-current  which  we  term  pain 
results. 

The  extreme  pain  accompanying  pleurisy,  that  caused  in  the  condition 
we  recognize  as  a  rheumatic  state  of  the  nerves  distributed  to  the  inter- 
costal muscles,  and  the  pain  excited  during  inflammation  even  of  very 
small  portions  of  the  subcutaneous  tissues,  as  in  the  formation  of  a  boil, 
or  even  in  the  case  of  a  chilblain,  are  illustrations  of  the  exquisite  sensi- 
tiveness of  nerves  in  textures,  of  the  existence  of  which  in  the  normal 
state  we  are  perfectly  unconscious.  In  all  these  cases  the  actual  nerve- 
fibres  involved  are  probably  those  which  r,un  very  close  to  the  capillary 
vessels  of  the  respective  tissues. 

Eruptions,  particularly  of  a  vesicular  character,  often  occur  in  the 
course  of  sensitive  nerves,  and  particularly  in  the  course  of  nerves  which 
are  very  commonly  the  seat  of  neuralgic  pain.  Whether  the  sensitive 
nerve  trunk  is  directly  involved,  or  whether  the  fibres  distributed  to  the 
capillary  vessels  of  the  nerve  trunk  and  of  the  skin  situated  over  the 
nerve  only  are  affected,  it  is  not  possible  to  say.  What,  however,  seems 
quite  certain  is  that  the  vesicles  of  an  eruption  which  generally  is  her- 
petic  in  its  character  follow  the  course  of  the  nerve.  The  pathological 
disturbance  resulting  in  the  formation  of  the  vesicles  may  be  of  a  most 
complex  nature,  in  which  reflex  nervo-vascular  action  plays  a  highly  im- 
portant part.  There  must  be  increased  nutrition,  with  pouring  out  of 
fluid  from  the  capillary  vessels,  and  this  phenomenon  is  probably  due 
to  the  relaxation  of  the  muscular  fibre-cells  of  the  small  arteries  and 
consequent  enlargement  of  their  calibre.  This  change  is  caused  by 
disturbance  in  the  nerve-centre  which  governs  the  arterial  contraction 
and  dilatation.  The  central  disturbance  may  itself  be  due  to  impulses 
emanating  from  the  sensitive  nerve  itself,  or  originating  in  the  skin  situ- 
ated over  its  course  and  transmitted  thence  by  afferent  fibres  connected 
with  the  centre.  In  this  manner  it  is  very  probable  that  various  pecu- 
liar eruptions  and  other  disturbances  connected  with  the  nutrition  of 
the  skin  and  subjacent  structures  are  occasioned. 

But  besides  the  alteration  in  the  sensibility  of  the  mucous  membrane 
in  sore  throat,  important  changes  take  place  in  connection  with  reflex 
nervo-muscular  action.  You  are  all  no  doubt  aware  that  if  the  fauces 
be  tickled  ever  so  slightly,  convulsive  movements  of  swallowing  will 
instantly  follow,  if  the  mucous  membrane  be  in  a  healthy  state.  In 


CO  UNTER-IRRITA  TION. 

slight  "  sore  throat  "  it  will  be  found  that  the  response  to  slight  irritation 
is  slow  and  imperfect,  while  in  severe  forms  of  inflammation  no  efforts 
of  deglutition  can  be1  excited  even  by  severe  irritation.  The  changes 
in  question  are  dueQo  an  alteration  in  the  sensitiveness  of  the  mucous 
membrane,  and  probably  depend  upon  pressure  or  stretching  of  the 
delicate  nerve-fibres,  in  consequenoe  of  which  they  cease  to  conduct 
impressions  from  the  periphery  to  the  nerve-centres. 

The  dry  state  of  the  surface  which  is  induced  by  slight  inflammation 
of  the  mucous  membrane  may  last  for  a  short  time  and  then  gradually 
subside,  without  any  further  pathological  action.  If,  however,  the  dryness 
and  diminished  secretion  should  persist  for  some  weeks,  restoration  to 
the  ordinary  condition  takes  place  very  slowly,  and  before  the  healthy 
state  can  be  resumed  a  condition  opposite  to  that  of  dryness  supervenes. 
Secretion  is  poured  out,  it  may  be,  in  very  considerable  quantity.  This 
tendency  to  secretion,  being  once  established,  may  persist  for  days  or 
weeks,  and  then  begin  to  diminish  in  amount.  By  degrees  the  glands 
return  to  their  normal  state  of  slight  activity,  secreting  only  a  very  small 
amount  of  transparent  viscid  mucus. 

Counter- action,  Counter-irritat:on. — But  we  may  reduce  the  secre- 
tion consequent  upon  exaggerated  and  abnormal  a-\ion  occurring  upon 
a  mucous  surface  by  proceeding  in  another  way.  Instead  of  trying  to 
act  directly  upon  the  membrane  which  is  the  seat  o?  the  increased  action, 
we  may  endeavor  to  establish  increased  action  of  surfaces  or  organs  at  a 
distance,  situated  in  different  parts  of  the  body.  In  this  way  we  may,  for 
example,  diminish  the  inflammation  and  undue  acuon  which  are  going 
on  in  the  surface  of  the  nose  in  many  cases  of  catarrhal  inflammation. 

I  will  now  direct  attention  to  an  important  principle  connected  with 
the  treatment  of  disease — a  principle  which  has  been  acted  upon  for  years, 
or  even  centuries,  and  concerning  which  we  are  much  better  informed 
than  our  predecessors  were.  That  we  can  reduce  the  rate  or  degree  of 
action  in  one  part  of  the  body  by  increasing  it  in  another  may  be  proved 
by  a  simple  experiment.  When  a  cold  is  coming  on,  you  feel  great  dis- 
comfort about  the  nose,  the  mucous  membrane  of  which  cavity  is  so 
swollen  that  the  nasal  passages  are  obstructed,  so  that  if  you  try  to- force 
air  down  one  nostril,  you  fail,  or  only  a  little  air  can  be  forced  through 
if  a  great  effort  be  ma  le.  You  are  obliged  under  these  circumstances 
to  breathe  entirely  through  the  mouth.  The  discomfort  caused  by  the 
swollen  state  of  the  mucous  membrane,  depending  partly  upon  exuda- 
tion into  the  submucous  tissue  and  partly  upon  increased  nutrition  going 
on  in  the  epithelial  covering,  may  be  ameliorated  in  a  very  short  period 
of  time  and  in  a  very  simple  way.  Let  the  feet  be  put  into  water,  as 
hot  as  you  can  bear  it  without  severe  pain.  In  the  course  of  a  quarter 
of  an  hour  the  disagreeable  feeling  of  fulness  and  obstruction  in  the 
nose  will  cease.  The  air  will  pass  through  the  passages  of  the  nose 
quite  freely.  By  increasing  the  flow  of  blood  in  the  vessels  of  the  skin 


254  CHANGES    TAKING  PLACE. 

of  the  lower  extremities,  much  of  the  circulating  fluid  will  be  diverted, 
for  the  time  being,  from  the  mucous  membrane  of  the  nose. 

Many  cases  of  headache  are  also  relieved  by  putting  the  feet  into  hot 
water.  If  instead  of  this  a  mustard  poultice  be  allied  to  the  back  of 
the  neck  a  similar  effect  will  follow.  As  soon  as  the  mustard  poultice 
begins  to  act,  the  vessels  or,  more  correctly,  the  nerve-fibres  distributed 
to  the  capillaries  ramifying  just  beneath  the  epithelium,  after  being  first 
irritated  and  then  poisoned  by  the  oil  of  the  mustard,  take  part  in  irri- 
tating changes,  which  result  in  the  vessels  becoming  red  and  turgid  from 
the  increased  quantity  of  blood  which  is  driven  into  them.  The  blood 
in  these  vessels  circulates  more  slowly  and  gradually  accumulates  in  them, 
the  surface  becoming  red  and  exceedingly  painful.  Corresponding  with 
this  increased  action  in  the  healthy  part  we  have  reduced  action  at  the 
seat  of  the  morbid  change. 

In  this  way  we  are  able  to  effect  alterations  which  are  of  immense 
importance  in  the  treatment  of  many  different  forms  of  disease.  In 
cases  where  the  morbid  action  is  chronic,  we  keep  up  the  counter- 
irritation  to  a  moderate  extent,  or  we  repeat  the  application  of  the 
counter-irritant  from  time  to  time.  Even  in  very  chronic  diseases  there 
is  good  reason  for  adopting  this  principle  of  treatment.  In  some  cases 
of  phthisis,  where  there  was  reason  to  infer  that  tubercle  was  limited  to 
a  very  small  extent  ofr  pulmonary  tissue,  benefit  seems  to  have  resulted 
from  keeping,  a  small  open  sore  on  the  skin  of  the  upper  part  of  the 
chest  on  the  same  side  of  the  body.  This  is  a  form  of  "issue."  In 
these  days,  however,  this  system  of  treatment  is  now  rarely,  perhaps  too 
seldom,  employed. 

It  is  not  uncommon  to  find  slight  pathological  derangements  of  the 
skin  and  mucous  membrane  of  the  lips.  This  surface  becomes  more  or 
less  dry,  and  the  epithelium  of  the  red  part  of  the  lip  which  resembles 
that  covering  the  skin,  only  forming  a  thinner  layer,  as  well  as  the  soft, 
moist  epithelium  lining  the  cavity  of  the  mouth,  becomes  deranged  in  its 
growth.  The  surface,  instead  of  remaining  quite  smooth,  becomes  more 
or  less  harsh.  Under  these  circumstances  the  patient  often  attempts  to 
make- the  surface  even  by  rubbing  it,  so  as  to  remove  the  little  project- 
ing pieces  of  ragged  cuticle.  In  this  way  the  derangement  is  kept  up 
or  intensified.  The  cuticle  tends  to  peel  off  in  thin  laminae,  and  many 
people  cannot  resist  the  temptation  to  catch  at  the  pieces  and  tear  them 
away.  But  then  the  surface  becomes  raw  and  often  bleeds.  In  conse- 
quence of  the  air  coming  into  contact  with  it,  the  moisture  soon  disap- 
pears, and  the  soft,  imperfectly-formed  cuticle  soon  gets  dry,  and  the 
surface  becomes  corrugated  and  more  painful  than  ever. 

By  the  irregular  growth  of  epithelium  the  arrangement  of  the  finest 
nerve-fibres  is  disturbed,  and  constant  irritation  gives  rise  to  irregular 
stretchirg  or  pressure.  The  sensations  thus  caused,  and  rapidly  suc- 
ceeding one  another,  excite  the  patient's  constant  attention,  and  in 


PRINCIPLES  OF  TREATMENT.  2$$ 

consequence  he  continually  rubs  the  affected  part  or  keeps  constantly 
picking  at  any  loose  portion  of  cuticle.  Immediately  around  the  irri- 
tated nerve-fibres  are  multitudes  of  particles  of  living  bioplasm  actively 
growing  and  multiplying,  forming  a  mass  of  soft,  very  moist  spongy 
matter,  the  constituent  particles  of  which  are  always  changing  in  posi- 
tion. The  drying  that  is  proceeding  on  the  surface  necessarily  disturbs 
the  nerve-fibres,  as  well  as  other  structures  beneath.  Schoolboys  are 
very  prone  to  pick  their  lips  when  in  this  state  and  make  them  extremely 
sore,  particularly  at  the  line  where  the  thin  skin  of  the  lip  joins  the 
ordinary  skin,  and  at  the  angles  of  the  mouth,  where  little  cracks  or 
fissures  often  form,  which  may  remain  for  days  or  weeks,  sometimes 
giving  rise  to  ugly  and  troublesome  sores.  It  is  very  desirable  to  pre- 
vent the  irritation  which  so  disturbs  the  patient  and  causes  him  to  make 
the  sore  worse  and  retard  the  healing. 

Principles  of  Treatment. — Now,  upon  what  principles  should  the 
treatment  of  such  simple  excoriations  and  slight  superficial  ulcerations 
be  based  ?  Our  main  object  should  be  to  reduce  the  growth  and  multi- 
plication of  the  particles  of  bioplasm  which  are  instrumental  in  keeping 
the  fissure  moist  and  open.  This  cannot  be  effected  by  causing  them 
to  dry  up,  because  in  that  case  a  little  crust  would  soon  form,  which,  in 
consequence  of  the  contraction  produced  by  desiccation,  would  after- 
wards be  drawn  away  from  the  subjacent  parts.  In  this  manner  a  raw 
surface  again  appears,  and  is  perhaps  larger  than  the  preceding  one.  At 
the  same  time  we  must  try  to  prevent  this  drying  up,  and  to  reduce  the 
growth  of  bioplasm  and  pouring  out  from  the  blood  of  fresh  plasma 
containing  more  bioplasm  particles.  By  effecting  these  objects,  certain 
lotions  and  other  local  applications  promote  healing.  Some  of  them 
lead  to  the  quick  formation  of  a  dry  scab,  but  so  thin  that  it  does  not 
become  detached.  Other  applications  are  employed  for  the  purpose  of 
reducing  the  rate  of  growth  of  the  masses  of  bioplasm  on  the  surface 
of  the  sore,  which  is  at  the  same  time  kept  moist.  The  formation  of 
the  more  permanent  tissues  slowly  proceeds  beneath  this  temporary  pro- 
tective covering.  This  latter  process  requires  a  considerable  time  for  its 
completion.  Much  formed  material  has  to  be  slowly  produced  by  the 
bioplasts  of  the  several  tissues,  and  must  subsequently  become  condensed. 

Alcohol. — One  of  the  most  potent  applications  for  healing  such  slight 
sores  as  I  have  referred  to  is  alcohol.  The  sore  place  may  be  painted 
over  once  in  an  hour  or  so  with  pretty  strong  spirit,  a  camel-hair  brush 
being  used  for  the  purpose.  Of  course,  there  is  a  sharp  pain  at  the 
moment  the  alcohol  comes  into  contact  with  the  delicate  nerve-fibres, 
but  it  soon  passes  off.  In  many  cases  it  is  well  to  dilute  the  alcohol 
with  an  equal  quantity  of  water  or  rose-water.  It  matters  little  whether 
you  use  any  of  the  ordinary  spirits  or  Eau  de  Cologne,  but  pure  spirits 
of  wine  diluted  with  one-third  part  of  pure  water  is  the  best  applica- 
tion. By  this  treatment  the  thin  skin  on  the  surface  of  the  fissure  or 


256  NITRATE  OF  SILVER. 

ulcer  becomes  hardened,  and  the  soft,  new  epithelium  that  is  being 
formed  beneath  will  become  condensed,  and  the  new  cuticle  will  grad- 
ually assume  the  usual  character  of  that  tissue.  Let  us  consider  how 
alcohol  acts  advantageously  under  these  circumstances.  By  its  property 
of  coagulating  albuminous  matters,  alcohol  tends  to  retard  rapid  growth 
and  to  interfere  with  the  multiplication  of  those  particles  of  bioplasm 
which  are  growing  so  rapidly  just  outside  the  capillaries.  The  bioplasm, 
as  I  have  mentioned,  is  growing  so  very  fast  that  there  is  not  time  for 
the  development  and  consolidation  of  that  firm,  healthy-formed  material 
which,  with  living  matter  within,  constitutes  a  cuticle  cell.  By  applying 
alcohol,  then,  you  favor  the  formation  of  cuticular  cells.  Wherever  the 
cuticle  is  thin,  by  painting  it  frequently  with  alcohol,  you  promote  the 
formation  of  cuticle  and  assist  the  condensation  and  increase  in  thick- 
ness of  the  new  tissue. 

If  there  should  be  sores  in  the  mouth ;  or  if  the  mucous  membrane 
of  the  gum  should  be  soft  and  spongy  from  the  infiltration  of  fluid  in 
the  substance  of  the  mucous  membrane,  the  surface  of  which  may  be 
very  red  and  tender,  the  morbid  action  may  be  quickly  counteracted  by 
painting  the  part  three  or  four  times  a  day  with  spirits  of  wine,  Spiritus 
Vini  Rectificatus,  or  some  other  form  of  alcohol,  or  with  spirits  of  Cam- 
phor, Spiritus  Camphor &. 

Solution  of  Nitrate  of  Silver. — Many  lotions  composed  of  metallic 
salts  are  employed  in  the  treatment  of  sores.  Most  of  them  act  by  virtue 
of  their  property  of  coagulating  and  precipitating  and  forming  com- 
pounds with  albuminous  matters.  Among  these  salts  is  Nitrate  of  Silver, 
Argenti  Nttras,  which  causes  the  sores  to  heal  very  quickly.  With  a 
small  camel-hair  brush  you  paint  the  fissure  with  a  little  solution  of 
Nitrate  of  Silver,  consisting  of  from  five  to  ten  grains  of  the  Nitrate  in 
an  ounce  of  Distilled  water.  This  will  give  pain  for  the  moment,  but 
the  soreness  soon  passes  off.  The  growth  and  multiplication  of  the 
masses  of  bioplasm  are  prevented.  Time  is  allowed  for  the  young  cells 
of  cuticle  to  harden.  Gradually,  new  skin  is  formed,  the  growth  of 
healthy  epithelium  is  favored,  and  before  long  the  healing  process  is 
completed. 

Conjunctiva. — A  good  illustration  of  the  pathological  changes  which 
occur  when  a  complex  tissue  becomes  inflamed  is  afforded  by  the  mucous 
membrane  which  covers  the  front  of  the  eye  and  lines  the  eyelids,  the 
Conjunctiva, — when  in  a  state  of  inflammation.  This  moist  mucous 
membrane  is  very  highly  sensitive,  and,  as  all  have  occasionally  ex- 
perienced, readily  becomes  inflamed.  If  you  go  out  in  foggy  weather, 
and  afterwards  examine  the  conjunctiva,  you  will  often  find  many  of  its 
vessels  distended,  and  you  will  observe  that  it  is  much  redder  than  it 
was  before  it  was  exposed  to  the  deleterious  effects  of  the  irritating  sub- 
stances which  are  suspended  in  the  air  in  a  fog.  The  pathological  change 
in  question  is  a  reflex  action  due  to  disturbance  in  the  nerve-centres 


INFLAMMATION  OF  THE    CONJUNCTIVA. 

induced  by  the  poisonous  action  of  the  irritating  matter  on  the  pe  'ipheral 
ramifications  of  the  sensitive  afferent  nerves,  and  a  consequent  paralyzing 
influence  upon  the  nerves  of  the  little  arteries.  In  the  case  of  persons 
who  are  in  a  low  state  of  health  who  have  lived  badly  for  some  time, 
and  especially  in  those  who  belong  to  scrofulous  families,  there  is  in- 
creased liability  to  inflammation  of  the  conjunctiva,  as  well  as  the  glands 
and  other  structures  which  are  connected  with  it.  When  the  mucous 
membrane  is  inflamed  the  little  glands  participate,  and  from  them  is 
poured  out  an  abundant  secretion- containing  numerous  particles  of  bio- 
plasm. The  vessels  are  distended,  and  that  part  of  the  mucous  mem- 
brane which  lines  the  eyelids  and  covers  the  white  part  (sclerotic)  of  the 
eye  is  reddened  and,  as  I  have  remarked,  in  a  state  which  well  illustrates 
the  changes  taking  place  in  inflammation.  The  condition  is  called 
Ophthalmia  or  Conjitnctivitis,  and  is  of  great  scientific  interest,  because 
a  transition  from  the  normal  or  ordinary  state  of  health  to  the  abnormal 
and  temporary  state  of  inflammation  may  be  studied  in  its  gradations. 
It  is  easy  to  examine  the  membrane  from  time  to  time  with  a  lens,  and 
without  causing  the  slightest  pain  or  inconvenience  to  the  patient. 

The  conjunctiva,  especially  in  ill-fed,  ill -nourished  scrofulous  children, 
not  only  readily  takes  upon  itself  this  exaggerated  action,  but  passes  into 
a  state  of  inflammation  which,  though  slight  for  a  time,  may  soon  be- 
come severe,  and  be  accompanied 'with  an  abundant  formation  of  a  yel- 
lowish secretion.  If  a  little  of  the  discharge  is  examined  in  the  micro- 
scope, it  will  be  found  to  consist  of  multitudes  of  particles  of  living 
matter,  well  known  as  pus-corpuscles.  Such  is  the  virulence  of  these 
particular  living  particles  that  if  no  more  of  the  discharge  than  can  be 
carried  on  the  point  of  a  needle,  be  transferred  to  the  surface  of  the 
eye  of  another  person,  a  similar  pathological  state  is  quickly  established 
upon  it.  Serious  inflammation  is  excited,  and  the  same  series  of  phe- 
nomena recur.  From  this  case  the  poison  may  be  transferred  to  a  third, 
and  so  on. 

Now,  if  many  children  in  weak  health,  who  for  some  time  previously 
have  been  badly  managed  as  regards  food,  air,  exercise,  and  cleanliness, 
are  allowed  to  congregate,  and  especially  if  they  are  confined  in  close, 
ill-ventilated  rooms,  the  disease  may  not  only  arise  but  soon  acquire  an 
extraordinary  degree  of  virulence.  It  may  spread  so  quickly  in  such  a 
community  of  children,  that  in  a  short  time  out  of  four  or  five  hundred, 
one-third  or  even  a  larger  proportion  may  be  suffering  from  the  disease. 
Of  the  number  affected  many  will  suffer  severely,  and  serious  structural 
changes  in  the  membrane  and  in  subjacent  tissues  will  result.  The  trans- 
parent part  of  the  eye  in  front,  known  as  the  cornea,  may  ulcerate,  and 
when  after  some  time  it  heal?,  the  tissue  will  be  so  altered  that  the  very 
transparent  texture  will  become  opaque,  or  the  eye  itself  may  be  destroyed, 
blindness  of  course  resulting  in  either  case. 

This  very  virulent  poison  of  purulent  ophthalmia  may,  as  I  have  re- 
22*  R 


258  TREATMENT. 

marked,  be  evolved  in  the  first  instance  without  contagion.  The  con- 
tagious  material  may  originate  upon  the  membrane  which  during  its  for- 
mation passes  from  the  normal  into  a  pathological  condition.  A  highly 
contagious  poison  may  also  be  developed,  in  the  organism  of  a  person 
suffering  from  peritonitis  and  some  other  inflammatory  and  febrile  dis- 
eases. In  this  case  it  *is  to  be  remarked  that  the  surfaces  upon  which 
the  changes  occur  which  result  in  the  development  of  the  contagious 
poison  are  not,  and  never  have  been,  exposed  to  the  air.  The  contagious 
matter  once  developed,  however,  may  spread  far  and  wide,  and  with  a 
rapidity  which  is  quite  remarkable.  You  see,  therefore,  that  an  animal 
poison  may  be  developed  of  a  highly  contagious  kind,  the  most  minute 
portion  of  which,  not  more  than  would  remain  on  the  point  of  the  finest 
needle,  would  establish  the  same  series  of  pathological  phenomena  in  a 
comparatively  healthy  tissue  if  transferred  to  it.  Probably  many  of  the 
pus-corpuscles  found  on  the  surface  of  the  conjunctiva  in  a  case  of 
purulent  ophthalmia  do  not  result  from  the  particle  inoculated.  Some, 
no  doubt,  are  formed  from  the  young  bioplasts  of  conjunctival  epithe- 
lium. There  are,  therefore,  two  kinds  of  bioplasm  growing  and  multi- 
plying at  the  same  time,  but  so  intermingled  that  it  would  not  be  pos- 
sible to  obtain  particles  of  each  kind  separately. 

In  inflammation  of  the  conjunctiva,  not  the  least  important  of  the 
phenomena  is  the  dilatation  of  the  vessels.  Of  the  little  arteries,  many 
are  dilated  to  three  times  their  ordinary  diameter,  and  the  capillaries 
are  also  distended  and  choked  with  blood.  Capillary  vessels  so  small 
that  hardly  a  single  row  of  red  blood-corpuscles  would  lie  in  them  and 
quite  invisible  in  the  ordinary  state,  become  so  large  in  inflammation 
and  are  so  filled  with  blood  that  through  an  ordinary  lens  they  can  be 
seen  as  distinct  dark-red  lines.  The  injection  of  the  vessels  may  con- 
tinue for  many  days  and  then  pass  off,  or  it  may  become  chronic,  when 
other  pathological  changes  take  place  in  consequence.  The  influence 
of  the  nerves  and  nerve-centre  in  these  vascular  changes  has  been  already 
considered  in  page  235. 

Treatment. — Inflammation  of  the  conjunctiva  requires  to  be  carefully 
treated.  It  is  undesirable  to  allow  this  inflammation  to  go  on,  especially 
in  children,  because  it  may  reach  a  stage  in  which  there  is  danger  of 
•damage,  not  only  to  that  very  important  structure  of  the  eye,  the  cornea, 
the  clearness  of  which  is  essential  to  distinct  vision,  but,  as  before  re- 
marked, to  the, whole  organ.  Good  hygienic  conditions  are  essential 
in  the  treatment  of  the  disease  as  it  occurs  in  children  ;  and  it  is  very 
important  to  look  for  and  relieve  that  preliminary  state  of  inflammation 
and  enlargement  of  the  glands  in  the  membrane,  which  almost  invariably 
precedes  an  attack  of  purulent  ophthalmia. 

Many  astringent  substances  are  of  use  in  the  treatment  of  inflamma- 
tion of  the  conjunctiva.  These  may  be  applied  in  various  ways.  In 
former  days  it  was  the  practice  to  project  a  small  quantity  of  some 


EYE-LO  TIONS.  259 

astringent  powder  on  the  surface  of  the  inflamed  conjunctiva,  by  placing 
a  little  of  the  powder  in  a  quill  or  piece  of  straw  and  blowing  it  suddenly 
upon  the  eye,  which  was  kept  open  for  the  moment.  These  powders 
were  usually  made  of  sugar  and  the  potent  substance,  in  the  proportion 
of  from  ten  parts  or  more  of  the  former  to  one  part  of  the  latter,  the 
whole  being  very  finely  powdered  and  carefully  mixed.  Oxide  of  Zinc, 
Nitrate  of  Potash,  Alum,  Sulphate  of  Copper,  Nitrate  of  Silver,  and 
other  substances'  have  been  used  in  this  way.  But  the  practice  is  a 
bad  one,  and  has  been  almost  entirely  abandoned  in  favor  of  solutions, 
which  may  be  applied  as  drops  or  by  using  an  eye-glass  or  an  eye-fountain. 
Strong  astringent  applications  should  never  be  used  except  under  proper 
advice,  or  serious  damage  to  the  eye  may  result. 

Of  Lotions  and  Eye  Waters. — One  of  the  best  is  a  weak  solution  of 
Sulphate  of  Zinc,  Zinci  Sulphas,  in  water ;  or,  if  you  wish  to  order  a 
more  elegant  lotion,  in  Rose  Water,  Aqua  Rostz.  As  regards  the  quan- 
tity, you  may  prescribe  from  a  quarter  of  a  grain  to  a  grain  to  the  ounce 
of  water.  A  very  dilute  solution  will  often  produce  a  favorable  change 
in  cases  of  mild  inflammation  of  the  conjunctiva,  in  a  few  hours.  Sugar 
of  Lead,  Plumbi  Acetas,  or  Sulphate  of  Copper,  Cupri  Sulphas,  may  be 
used  in  the  same  proportion  as  Sulphate  of  Zinc ;  but  the  latter  and 
Nitrate  of  Silver,  Argenti  Nitras,  are  probably  the  most  useful.  Of 
the  last,  the  proportion  should  be  half  a  grain  or  less  to  an  ounce  of 
distilled  water.  If  the  eye  is  very  painful,  a  grain  of  Opium  or  two  or 
three  drops  of  Laudanum,  Tinctura  Opii,  to  the  ounce  of  water  may  be 
prescribed.  In  all  cases  the  solution  should  be  carefully  filtered  before 
it  is  applied.  A  lotion  consisting  of  Spirits  of  Wine,  Spiritus  Vint 
Rectificatus,  or  good  brandy,  Spiritus  Vini  Gallici,  in  the  proportion 
of  one  part  to  thirty  or  more  parts  of  water,  has  also  been  recommended  ; 
and  where  the  vessels  are  dilated  without  any  production  of  pus,  the 
careful  application  of  a  weak  spirit  solution  may  be  useful.  • 

Lotions  may  be  applied  to  the  surface  of  the  eye  in  two  or  three  differ- 
ent ways.  One  of  he  best  methods  is  to  seat  the  patient  in  a  chair  and 
make  him  throw  his  head  back.  You  then  take  a  good-sized  camel-hair 
brush  which  will  take  up  two  or  three  drops  of  the  lotion,  which  may 
thus  be  caused  to  flow  into  the  inner  corner  of  the  affected  eye.  Of 
course  the  patient  will  instinctively  close  the  eye  at  the  moment,  but  he 
must  be  encouraged  to  open  the  lids  a  little,  so  that  some  of  the  solution 
may  pass  in  and  the  surface  of  the  conjunctiva  be  thoroughly  moistened 
by  it  in  every  part. 

Another  plan  is  to  bathe  the  eye  with  an  ordinary  sponge  or  rag,  but 
you  must  always  be  most  careful  that  the  particular  sponge  or  rag  is  used 
for  no  other  purpose  whatever.  Where  there  are  several  patients,  each 
must  have  his  own  sponge,  towel,  etc.,  kept  exclusively  for  his  own  use. 

Another  way  of  applying  lotions  to  the  conjunctiva  is  with  the  aid  of 
an  Eye-glass.  This  is  a  little  glass  made  something  like  a  small  wine- 


260  SO  KB    THROAT. 

glass,  the  free  edge  Leing  shaped  so  as  to  fit  within  the  margin  of  the 
orbit.  The  eye-glass  is  half-filled  with  the  lotion,  and  the  patient  is 
directed  to  hold  the  glass  steadily  against  the  eye,  while  the  head  is  to 
be  moved  about  in  such  a  way  as  to  cause  the  fluid  to  splash  against  the 
surface  of  the  conjunctiva.  The  glass  acts  so  as  to  keep  the  lids  open, 
and  in  this  way  you  ensure  the  lotion  coming  in  contact  with  the  surface 
of  the  mucous  membrane.  Lastly,  there  is  the  little  Eye-douche  ar 
Fountain,  by  the  aid  of  which  a  jet  of  lotion  can  be  thrown  against  the 
eye.  All  these  instruments  may  be  obtained  of  surgical  instrument 
makers. 

Astringent  lotions  generally  by  their  indirect  action  upon  the  nerves 
of  the  part,  and  by  their  direct  action  upon  the  particles  of  bioplasm 
which  are  growing  and  multiplying,  favor  the  formation  of  the  firm 
material,  upon  which  the  consistence  and  the  protective  character  of  the 
epithelium  depends,  and  its  subsequent  condensation.  Thus  a  "raw," 
or  nearly  raw,  surface  again  gradually  becomes  protected  with  a  layer  of 
ordinary  slow-growing  epithelial  tissue. 

Sore  Throat.— In  an  early  lecture  I  have  adverted  to  some  of  the 
changes  which  occur  in  sore  throat,  but  in  this  place  I  shall  consider  one 
or  two  questions  in  connection  with  the  subject  which  were  then  passed 
by.  Mo  t  of  us  have  suffered  more  or  less  from  this  affection.  In  the 
case  of  those  who  are  susceptible,  there  frequently  occurs  a  certain 
amount  of  congestion  and  inflammation  in  the  mucous  membrane  of  the 
fauces,  and  of  the  back  of  the  pharynx.  If  you  look  at  the  palate  in 
suih  a  case,  you  will  find  it  in  very  much  the  same  state  as  I  described 
when  referring  to  ihe  mucous  membrane  of  the  nose  in  an  ordinary  cold. 
Many  of  you  will  have  opportunities  of  making  the  observation  in  your 
own  persons.  You  may  easily  examine  the  fauces  with  the  aid  of  an 
ordinary  looking-glass.  Instead  of  the  membrane  appearing  moist,  you 
\v.A  find  it  near.y  dry,  and  perhaps  you  may  see  a  piece  of  half-dry  viscid 
mucus  intimately  adhering  to  it.  The  sensibility  of  the  membrane  is 
also  affected.  Although  it  feels  sore,  you  will,  however,  find  that  it  is 
less  sensitive  than  in  the  normal  state,  while  certain  of  its  nerves  do  not 
respond  so  readily  to  a  stimulus  as  they  do  in  health. 

If  the  throat  is  perfectly  healthy,  the  process  of  swallowing,  or  deglu- 
tition, is  easily  performed,  and  almost  unconsciously — at  least  without 
any  great  effort;  but  if  the  throat  is  sore,  deglutition  becomes  difficult, 
and  you  have  to.  make  a  very  decided  effort,  perhaps  more  than  one,  be- 
fore the  morsel  of  food  can  be  successfully  swallowed. 

Then  there  is  another  fact  of  some  importance  with  regard  to  the 
action  of  the  mucous  membrane.  Not  only  are  the  nerves  which  are 
connected  with  the  capillary  vessels,  and  which  are  concerned  in  the 
sensation  of  pain  and  discomfort,  obviously  affected,  but  those  which  are 
instrumental  in  exciting  by  reflex  action  the  contraction  of  the  pharyngeal 
muscles.  If,  in  the  normal  state  of  health,  you  tickle  the  soft  palate 


TREATMENT  OF  SORE    THROAT.  26 1 

ever  so  slightly  with  a  feather,  if  the  raucous  membrane  enjoys  its  proper 
sensitiveness,  movements  of  deglutition  almost  instantly  succeed.  But 
if  the  throat  is  "sore,"  the  mucous  membrane  red,  and  perhaps  dry, 
you  may  tickle  it  very  decidedly,  and  only  feeble  contraction  will  follow 
after  an  interval  of  time,  or  no  contraction  of  the  muscles  will  occur. 
In  this  action  the  muscular  fibres  fail  to  contract,  because  the  nerve-fibres 
which  carry  impressions  from  the  surface  of  the  mucous  membrane  to 
the  nerve-centre  are  deranged.  Their  action  for  the  time  being  is  pre- 
vented. There  is,  as  it  were,  a  peripheral  paralysis.  The  motor  nerve- 
fibres,  the  nerve-centre,  and  even  the  afferent  trunks  themselves,  may  be 
all  right ;  but  the  fine  ramifications  of  the  afferent  fibres  in  the  mucous 
membrane  are  so  affected  by  the  effusion  in  its  substance  and  other 
changes,  that  they  do  not  receive  and  transmit  impressions. 

When  sore  throat  attacks  persons  who  have  for  some  time  been  in  a 
low  state  of  health,  or  exposed  to  adverse  influences,  as  sometimes  hap- 
pens in  the  case  of  those  resident  in  workhouses,  hospitals,  jails,  and 
other  places,  it  may  run  on  very  quickly  to  extensive  superficial  ulcera- 
tion,  which  may  affect  the  substance  of  the  tonsil,  and  progress  for  several 
days.  The  fetid  products  resulting  from  the  decomposition  of  the  secre- 
tion taking  place  upon  or  near  the  ulcerated  surface,  are  sometimes 
absorbed  into  the  blood  and  occasion  a  form  of  blood-poisoning.  If 
swallowed,  the  discharges  give  rise  to  much  disturbance  of  digestion. 
It  is,  therefore,  most  important  in  the  treatment  of  such  cases  to  apply 
substances  to  the  surface  which  have  the  effect  of  completely  changing 
the  organic  matters  and  destroying  the  infecting  material. 

If  Diphtheria  exist  in  the  neighborhood,  persons  in  a  low  state  of 
health,  and  those  already  suffering  from  sore  throat,  are  very  likely  to 
take  the  disease,  which  sometimes  runs  its  course  so  very  quickly  that 
life  is  in  jeopardy  in  a  few  hours  after  the  malady  has  declared  itself,  or 
even  before  there  has  been  time  for  the  formation  of  a  false  membrane, 
or  for  the  development  of  any  characteristic  phenomena  of  the  disease. 
It  is,  therefore,  of  the  utmost  consequence  to  very  carefully  watch  cases 
of  sore  throat,  especially  when  of  an  epidemic  character.  You  should 
see  the  patient  at  intervals  of  a  few  hours,  and  you  should  give  quinine 
and  stimulants  early,  instead  of  waiting  until  the  patient  is  very  low. 
In  some  cases  of  what  is  called  "  hospital  sore  throat,"  as  well  as  in 
Diphtheria,  you  will  be  surprised  to  find  that  persons  may  take  in  twenty- 
four  hours  from  ten  to  thirty  grains  of  quinine,  and  eight  or  ten  ounces 
of  brandy,  divided  into  doses  given  every  two  hours,  wfthout  any  indi- 
cation of  the  quantity  of  either  remedy  being  excessive ;  and  it  may  be 
necessary  to  continue  this  treatment  for  many  days,  giving  at  the  same 
time  plenty  of  beef-tea  or  milk. 

The  Treatment  of  Sore  Throat. — We  are  often  consulted  by  patients 
who  complain  that  they  are  almost  constantly  suffering  from  soreness  of 
the  throat.  It  is  sometimes  better,  sometimes  worse,  but  they  will  tell 


262  APPLICATION  OF  ASTRINGENTS. 

you  the  throat  always  feels  rough  and  uncomfortable.  Many  local  appli« 
cations  are  of  great  use.  You  may  paint  the  fauces  with  a  solution  of 
Nitrate  of  Silver,  Argenti  Nitras,  but  a  stronger  solution  may  be  em- 
ployed than  was  recommended  for  applying  to  the  conjunctiva.  A 
solution  consisting  of  from  five  to  ten  grains  to  the  ounce  of  distilled 
water  answers  well,  or  you  may  employ  a  mixture  of  solution  of  Per- 
chloride  of  Iron,  Liquor  Ferri  Perchloridi,  and  an  equal  quantity  of 
glycerine,  Glycerinnm.  This  mixture  is  very  valuable  in  the  treatment 
of  sore  throat,  whether  it  be  mild  or  severe.  The  glycerine  causes  the 
Perchloride  of  Iron  to  adhere  to  the  surface  for  a  little  time,  and  in  that 
way  increases  its  beneficial  effects.  In  forms  of  sore  throat  in  which 
there  js  a  quantity  of  viscid  mucus,  accompanied  with  excoriations  or 
ulcers  on  the  palate  or-  tonsils,  the  mixture  may  be  applied  every  two 
hours,  or  oftener.  The  solution  is  a  potent  antiseptic,  and  destroys  any 
deleterious  properties  the  secretion  may  possess.  By  its  application 
efforts  of  vomiting  are  often  excited,  and  thus  much  of  the  secretion  is 
got  rid  of.  I  have  successfully  treated  in  this  way  many  bad  forms  of 
sore  throat,  which  by  some  would  be  called  li diphtheritic •."  The  condi- 
tion is  associated  with  great  depression  of  strength,  and,  as  I  have  before 
said,  it  is  necessary  to  give  quinine  and  wine  or  brandy  in  very  decided 
doses.  Any  of  the  foul  secretion  swallowed  by  accident  is  rendered 
innocuous  by  the  action  of  the  iron.  In  this  way  stomach  disturbance, 
so  apt  to  ensue  in  these  cases,  and  which  so  much  increases  the  risk  to 
life  when  it  does  occur,  may  be  prevented.  Tannin  dissolved  in  glyce- 
rine, Glycerinum  Acidi  Tannici,  is  also  a  good  application.  In  applying 
such  local  remedies,  whether  a  solution  of  Nitrate  of  Silver,  or  Glycerine 
and  Perchloride  of  Iron,  or  the  Tannin,  perhaps  the  following  will  prove 
to  be  the  best  plan.  Take  a  good  large  camel's-hair  brush,  which  must 
be  carefully  tied  to  the  end  of  a  stick.  This  latter  point  is  important, 
because  if  the  brush  is  simply  placed  on  the  stick,  it  may,  unfortunately, 
fall  off  at  a  critical  moment  and  be  swallowed  by  the  patient.  The 
possibility  of  the  occurrence  of  so  awkward  an  accident  may  be  thus 
prevented.  The  brush  is  to  be  thoroughly  wetted  with  the  applica- 
tion, and,  a  few  drops  being  taken  up  in  it,  the  wet  brush  is  to  be  well 
smeared  over  the  surface  of  the  affected  mucous  membrane.  After  a 
quarter  of  a  minute  the  patient  may  be  allowed  to  gargle  with  a  little 
cold  water. 

Although  severe  forms  of  sore  throat  cannot  certainly  be  included 
among  "slight  ailments,"  it  is  important  that  your  attention  should  be 
directed  to  the  general  treatment  of  the  patient.  I  have  no  doubt  that 
by  judicious  management  many  cases  are  prevented  from  assuming  a 
severe  form.  If  the  patient  gets  low  with  a  quick  weak  pulse,  especially 
if  ulceration,  which  may  be  present,  should  be  extending,  and  there  is 
infiltration  of  the  tissues  around  the  tonsils,  it  is  necessary  to  give  wine 
or  brandy  and  tonics,  such  as  iron  and  quinine.  One  is  often  surprised 


GARGLES.  263 

at  the  large  amount  of  supporting  remedies  required  in  some  of  these 
cases.  In  what  used  to  be  called  "hospital  sore  throat,"  we  often  find 
it  necessary  to  give  six  or  eight  five-grain  doses  of  quinine  in  the  four- 
and-twenty  hours,  and  as  much  as  twelve  or  more  ounces  of  brandy 
during  the  same  period,  and  this  treatment  may  have  to  be  maintained 
during  several  days. 

Gargles. — Various  gargles  are  used  in  the  treatment  of  sore  throat 
and  an  inflamed  or  aphthous  (p.  70)  state  of  the  mucous  membrane  of 
the  mouth.  The  influence  of  some  of  these  is  due  to  the  presence  of 
matter  having  astringent  properties,  while  others  depend  for  their  efficacy 
upon  some  form  of  alcohol. 

Port  wine  is  an  excellent  gargle  in  cases  of  ordinary  relaxed  sore 
throat ;  but  some  people  do  not  like  port  or  any  other  kind  of  wine,  and 
in  that  case  you  may  order  a  gargle  consisting  of  one  part  of  spirits  o-f 
wine  to  four  or  five  parts  of  water. 

Alum  used  to  be  a  favorite  remedy,  dissolved  in  a  little  water  in  the 
proportion  of  one  drachm  to  six  ounces. 

A  good  gargle  may  be  made  by  dissolving  a  drachm  of  Nitrate  of 
Potash,  Potasscz  Nitras,  or  Chlorate  of  Potash,  Potassa  Chloras,  in  six 
or  eight  ounces  of  water.  An  ounce  of  glycerine  or  honey  may  be 
added.  Some  like  gargles  made  acid  ;  for  this  purpose  you  may  order 
a  drachm  of  Dilute  Acetic,  Phosphoric  or  Hydrochloric  acid,  to  six  or 
eight  ounces  of  water. 

Many  persons  derive  benefit  from  the  use  of  a  stimulating  gargle, 
which  may  be  made  by  adding  a  little  Cayenne  pepper,  or  Tincture  of 
Capsicum,  Tinctura  Capsici,  in  the  proportion  of  one  drachm  or  less  to 
six  ounces  of  gargle ;  but  this  is  not  suitable  in  the  case  of  a  very  sensi- 
tive, irritable  mucous  membrane,  and,  indeed,  may  do  harm  instead  of 
good. 

Common  Salt  is  valuable  as  a  gargle.  A  weak  brine  may  be  made  by 
adding  a  dessert-spoonful  of  salt,  or  less,  to  half  a  pint  of  water.  The 
throat  may  be  gargled  with  this  solution  once  in  two  or  three  hours.  In 
ordering  gargles,  it  is  necessary  to  give  the  patient  exact  directions — to 
tell  him  to  use  the  gargle  frequently,  for  it  is  useless  to  gargle  once  or 
twice  in  the  four-and-twenty  hours.  If  the  sore  throat  is  at  all  severe, 
the  gargle  should  be  used  once  or  twice  in  the  hour. 

Of  exciting  increased  action  in  distant  parts. — You  may  sometimes 
relieve  a  sore  throat,  as  well  as  other  forms  of  local  inflammation  and 
congestion,  by  causing  increased  action  in  other  organs  and  tissues.  The. 
action  of  a  purgative  is  often  followed  by  the  relief  'of  the  throat  affec- 
tion. Diuretics  and  sudorifics  may  be  prescribed  with  the  same  object, 
and  counter-irritation  may  be  applied  in  some  other  part  of  the  body. 
A  mustard  poultice  to  the  neck,  by  establishing  increased  action  on  the 
cutaneous  surface,  often  reduces  the  congestion  of  the  mucous  membrane 
of  the  throat.  When  slight,  and  not  depending  upon  a  general  low 


264  INFLAMMATION  OF  AIR-TUBES. 

state  of  the  system,  or  altered  blood,  a  sore  throat  may  sometimes  be 
cured  in  this  way  in  a  couple  of  hours. 

Inflammation  of  the  Mucous  Membrane  of  the  Air  Passages. — Inflam- 
mation, as  has  been  already  remarked,  very  commonly  affects  the  mucous 
membrane  of  the  nose  and  all  the  cavities  which  open  into  it.  There 
is  increased  secretion  from  all  the  glands  and  follicles  opening  upon  the 
surface,  increased  formation  of  soft,  moist,  and  imperfectly  formed  epi- 
thelium, taking  the  form  of  mucus,  and  undue  turgescence  of  all  the 
vessels.  In  consequence  there  is  what  is  ordinarily  called  "  running 
from  the  nose." 

When  the  mucous  membrane  of  the  large  bronchial  tubes  is  inflamed, 
and  consequently  there  is  an  increased  formation  of  mucus  on  the  sur- 
face, we  have  an  ordinary  catarrh,  the  phenomena  of  which  have  been 
already  referred  to.  There  is  in  these  cases  also  congestion  of  the  fauces, 
increased  formation  of  mucus,  and  increased  action  of  the  glands.  The 
transition  from  the  ordinary  epithelial  cell  to  the  viscid  material  known 
as  mucus,  and  from  the  mucus-corpuscle  to  the  pus-corpuscle,  may  be 
observed  and  studied.  In  cases  in  which  the  inflammation  continues  for 
a  considerable  time,  instead  of  viscid  transparent  mucus  being  formed, 
we  meet  with  ordinary  pus,  or  pus  mixed  with  mucus,  which  is  known 
as  Miu'o-pus,  the  microscopical  characters  of  which  must  be  carefully 
studied,  as  well  as  those  of  other  kinds  of  sputum  formed  in  different 
cases  of  diseasj. 

What  is  termed  false  membrane,  or  croupous  exudation,  is  frequently 
formed  in  cases  of  inflammation  of  the  mucous  membrane  of  the  larynx, 
trachea,  and  bronchial  tubes.  I  have  seen  cases  in  which  a  complete 
and  firm  membranous  cast  of  these  passages  was  formed  on  the  surface 
of  the  mucous  membrane,  and  was  expelled  entire  after  much  suffering. 
The  firm  material  consisted  entirely  of  viscid  mucus.  Casts  of  the 
smaller  bronchial  tubes  are  also  sometimes  formed  of  mucus,  but  more 
commonly  they  will  be  found  to  consist  of  fibrinous  material  which  has 
been  poured  out  from  the  blood,  and  has  coagulated  in  the  air-tubes. 

Running  from  the  ears  is  common  among  children  of  what  is  called 
"  a  scrofulous  habit  of  body."  The  epithelium  of  the  meatus  undergoes 
change,  and  becomes  soft,  the  new  epithelium  being  imperfectly  formed, 
and  superabundant.  The  vessels  of  the  skin  are  also  congested.  After 
the  disturbance  has  existed  for  some  time,  the  discharge  resembles  that 
from  an  ulcerated  surface.  Not  unfrequently  the  discharge  dries  up  and 
forms  a  crust,  which  in  consequence  of  the  itching  and  irritation  excited, 
is  often  picked  off  by  the  patient.  A  raw  and  very  sore  surface  is  ex- 
posed, and  from  this  fresh  discharge  escapes,  which  in  turn  dries,  and 
then  follows  a  repetition  of  the  process.  The  condition  is  often  very 
obstinate  and  difficult  to  cure.  In  most  instances  constitutional  treat- 
ment by  iron  and  other  tonics  and  cod-liver  oil  is  absolutely  requisite. 


INFLAMMATION  OF  STOMACH.  26$ 

As  the  health  improves,  the  discharge  begins  to  diminish,  and  at  last 
ceases  altogether. 

Inflammation  of  the  Mucous  Membrane  of  the  Stomach  and  Intestinal 
Canal. — The  mucous  membrane  of  the  stomach  is  very  liable  to  conges- 
tion and  inflammation,  much  more  so,  I  think,  than  is  generally  supposed. 
From  time  to  time  these  pathological  changes  probably  affect  small  patches 
of  mucous  membrane,  last  for  a  time,  and  then  pass  off  if  the  mucous 
membrane  is  soothed  and  allowed  to  rest  from  active  work  fofr  a  few 
days. 

In  all  our  best  works  on  Medicine,  the  subject  of  Ulcer  of  the  stomach 
is  fully  treated  of,  but  there  is  a -state  of  things  allied  to  ulcer,  and  lead- 
ing to  it,  to  which  reference  is  seldom  made.  The  state  of  mucous  mem- 
brane to  which  I  allude  is  not  so  serious  as  ulcer,  but  it  is  much  more 
common,  and,  if  not  relieved,  may  be  succeeded  by  the  formation  of  an 
ulcer.  The  mucous  membrane  of  the  stomach,  like  the  nasal  and  bron- 
chial mucous  membrane,  "takes  cold."  It  becomes  red  and  less  moist 
than  in  the  normal  state.  There  is  often  great  discomfort  and  very  fre- 
quently severe  pain.  The  glands  are  more  or  less  affected,  and  the  func- 
tions of  the  stomach  are  very  seriously  disturbed.  The  secretion  of 
gastric  juice  is  interfered  with  and  its  qualities  changed.  Digestion  is 
of  course  deranged,  and  sometimes  completely  checked.  There  may  be 
much  flatulence,  .which  adds  to  the  distress.  Many  patients,  instead  of 
allowing  the  stomach  to  rest  for  a  while,  are  too  prone  to  call  for  food 
when  they  experience  any  uneasiness.  They  feel  exhausted,  and  think  a 
good  meat  meal  will  certainly  relieve  their  discomfort.  This  they  take, 
and  very  soon  find  they  have  made  a  mistake,  for  their  pain  is  increased. 
If  they  are  fortunate,  vomiting  will  be  excited,  and  all  that  has  been 
taken,  with  perhaps  other  matters  already  in  the  stomach,  will  be  rejected, 
when  considerable  relief  will  be  experienced.  When  you  Have  reason 
to  think  that  a  patient  is  suffering  from  this  slight  inflammation,  it  is  de- 
sirable to  at  once  carry  out  measures  for  his  relief,  and  effect  a  return  to 
the  healthy  state  as  soon  as  possible,  for  the  stomach  is  an  organ  .whose 
work  cannot  be  suspended  for  long  at  a  time  without  the  whole  organism 
suffering.  You  order,  therefore,  nutritious,  but  unirritating,  soft  or  liquid 
food  for  a  while,  and  then  take  care  that  for  the  next  few  weeks  only  food 
of  a  soothing  character,  and  which  will  be  very  easily  digested,  passes 
into  the  stomach.  The  patient  must  on  no  account  be  allowed  to  take 
ordinary  diet,  and  you  must  tell  him  not  to  touch  beer,  and  enjoin  him 
not  to  take  very  cold  or  very  hot  liquids  of'  any  kind.  Every  form  of 
alcohol  should,  as  a  general  rule,  be  withheld,  because  in  a  great  many 
instances  alcohol  only  irritates,  and  sometimes  greatly  increases  the  pain. 
It  may  do  much  harm,  though  it  must  be  admitted  that  not  unfrequently 
it  relieves  for  the  moment  the  discomfort  and  sinking  feeling  which  some- 
times distress  the  patient.  For  this  reason  it  is  imperative  to  be  cautious 
in  such  cases.  We  ought  never  to  give  people  any  excuse  for  perma- 
23 


266  CONGESTION  OF  SMALL   INTESTINE. 

nently  damaging  their  tissues,  by  acquiring  the  habit  of  taking  too  much 
alcohol. 

The  digestion  of  meat  almost  entirely  depends  upon  the  secretion 
formed  by  the  stomach  glands.  When  this  secretion  is  temporarily  de- 
ranged, it  is  better  to  allow  the  mucous  membrane  of  the  stomach  to  do 
as  little  work  as  possible.  Meat  and  fish  should,  therefore,  be  withheld 
for  a  time.  The  patients  should  be  put  on  a  milk  diet.  You  may  order 
them  to  take  bread  and  milk,  or  arrowroot  and  milk,  or  rice,  sago, 
tapioca,  maccaroni,  vermicelli,  and  cooked  in  such  a  manner  as  to 
make  a  very  soft  moist  food.  By  adopting  this  course,  the  patient  ap- 
plies something  like  a  poultice  to  the  disturbed  mucous  membrane  of 
his  stomach,  and  in  many  other  cases,  with  great  and  immediate  benefit. 
It  does  no  one  any  harm  to  live  on  soft  food  of  a  farinaceous  kind  for  a 
few  days  or  a  week.  Indeed,  not  a  few  would  gain  in  health  if  they  sys- 
tematically adopted  such  a  diet  for  a  week  or  two  once  in  every  two  or 
three  months.  A  very  good  substance  to  recommend  patients  to  eat 
under  these  circumstances,  only  you  will  find  many  will  refuse  to  eat  it, 
is  lentil  flour,  well  boiled  and  made  thick  like  gruel. 

Any  part  of  the  mucous  membrane  of  the  small  or  large  intestine  may 
be  affected  by  congestion  and  catarrhal  inflammation.  There  are  many 
cases  in  which  there  is  severe  pain  "  in  the  stomach,"  as  the  patient 
says,  but  which  depends  upon  derangement  of  some  part  of  the  small  or 
large  intestine.  The  mucous  membrane  may  be  congested  in  patches, 
and  the  action  of  the  follicles  and  of  the  villi  for  a  time,  becomes  seriously 
disturbed.  By  taking  care  that  only  bland  substances,  and  as  little  as 
possible  of  these,  pass  along  the  small  intestine  for  a  time,  the  mucous 
membrane  will  be  soon  restored  to  its  normal  state.  It  is  important  to 
check  such  disturbances  as  soon  as  possible.  Though  according  to  the 
patient  himself,  he  maybe  suffering  only  from  pain  "in  the  stomach," 
— if  he  do  not  take  complete  rest,  what  is  only  a  slight  ailment  may 
soon  become  a  grave  malady.  In  such  cases,  diet  is  of  more  conse- 
quence than  medicine,  but  if  the  pain  is  very  severe,  it  may  be  necessary 
to  give  small  doses  of  sedatives.  Advantage  also  results  from  employ- 
ing mild  counter-irritants  over  the  belly.  The  best  counter-irritant  is  a 
poultice  made  of  half  mustard  and  half  linseed-meal.  This  may  be 
applied  to  the  surface,  near  the  seat  of  pain,  and  it  unquestionably 
relieves  the  inflammation.  A  mustard  leaf  is  more  easily  prepared,  but 
a  piece  of  writing-paper  should  intervene  between  it  and  the  skin,  or 
the  action  will  be  too  strong,  and  the  patient  will  remove  it  before  there 
has  been -time  for  the  counter-irritant  to  have  done  good. 

The  external  application  of  warmth  greatly  relieves  pain  which  results 
from  a  congested  or  inflamed. state  of  the  mucous  membrane  of  the  intes- 
tinal canal.  A  linseed  poultice,. or  flannels  wrung  out  in  hot  water,  will 
be  of  service.  If,  however,  this  does  not  soon  afford  relief,  the  surface 
of  the  poultice  or  the  flannel  may  be  sprinkled  with  turpentine.  The 


TREATMENT  OF  CONGESTION  AND   INFLAMMATION.     267 

thick  India-rubber  bottle  for  hot  water  should  find  a  place  in  every  trav- 
eller's trunk.  It  is  most  useful  in  the  treatment  of  abdominal  and  other 
pain.  I  have  already  referred  to  it  on  p.  151. 

Stimulating  liniments  are,  as  a  general  rule,  not  advisable.  You  do 
not  want  to  move  the  bowels  about  in  the  least  degree,  or  to  disturb  the 
parts  at  all.  If  you  allow  people  to  rub  things  in,  the  chances  are  they 
add  to  the  sufferings  of  the  patient,  and  do  harm  to  tissues  already  tender 
and  irritable,  and  in  a  state  verging  upon  actual  disease.  This  rubbing 
in  of  liniments  is  often  adopted  most  injudiciously  for  every  kind  of 
pain,  and  you  not  unfrequently  find  a  self-constituted  and  most  self-con- 
fident medical  adviser  "  rubbing  away  !  "  the  pain  of  an  inflamed  joint. 
Many  nurses  and  ladies  having  a  turn  for  doctoring  require  to  be  cau- 
tioned on  this  head,  for  many  conditions  are  made  worse  by  rubbing, 
and  in  some  instances  very  serious  inflammation  may  be  excited  by  the 
operation. 

Congestion  and  inflammation  of  a  portion  of  the  mucous  membrane 
of  the  large  bowel  is  not  uncommon.  There  is  in  such  cases  severe  pain 
and  the  action  of  the  bowel  is  much  deranged.  The  condition  may  pass 
on  to  ulceration,  which  may  endanger  life.  Ulcers  frequently  form  in 
the  lower  part  of  the  small  intestines  in  cases  of  Typhoid  fever,  the  heal- 
ing of  which  is  always  a  very  slow  process.  Every  case  of  Typhoid 
fever  requires  the  most  careful  management  and  constant  attention,  not 
only  at  the  time  ulcers  are  forming  and  the  sloughs  separating,  but  dur- 
ing the  healing  process.  Though  this  disease  cannot  be  included  among 
"slight  ailments,"  it  is  very  desirable  that  you  should  know  that  health 
is  only  very  slowly  restored,  and  that  three  months  sometimes  pass 
before  a  patient  suffering  from  Typhoid  can  with  safety  be  allowed  to 
resume  his  usual  diet  and  habits  of  life.  All  attempts  to  hasten  conva- 
lescence are  unwise,  and  every  now  and  then  a  patient  is  lost  in  conse- 
quence. Full  time  must  always  be  allowed  for  the  healing  of  ulcers  in 
any  part  of  the  alimentary  canal. 

There  happens  to  be  just  now  a  case  of  mild  dysentery  under  my  care 
in  the  hospital.  The  man  suffers  much  pain,  and  from  the  usual  symp- 
toms. He  passes  liquid  motions  with  a  good  deal  of  mucus.  In  this 
case  we  are  adopting,  with  the  greatest  benefit,  a  mode  of  treatment 
which  may  be  considered  "empirical,"  (f^nsipia,  experience;)  for, 
although  the  remedy  employed  is  undoubtedly  useful,  we  do  not  know 
precisely  how  it  acts.  Ipecacuanha  powder  is  of  the  greatest  value  in 
many  such  cases — not  only  where  there  is  actual  ulceration  of  the 
mucous  membrane  of  the  colon,  but  where  there  is  an  approach  or  ten- 
dency to  this  condition.  In  India  this  drug  is  much  used  in  the  treat- 
ment of  dysenteric  affections.  You  may  begin  with  doses  of  two  or 
three  grains  of  Ipecacuanha,  in  the  form  of  a  powder  or  pill,  and  you 
may  increase  the  dose  up  to  twenty  grains  or  more,  twice  or  three  times 
a  day;  or  five  or  ten  grains  may  be  given  with  a  half  a  grain  or  less  of 


268  CHILBLAINS. 

opium,  which  will  prevent  its  emetic  action.  Some  persons  cannot  take 
opium,  and  in  this  case  the  Ipecacuanha  must  be  given  at  first  in  small 
doses.  The  medicine  may  be  continued  until  the  symptoms  are  greatly 
relieved.  In  many  cases  the  patient  is  completely  cured  in  a  month  or 
six  weeks. 

If  you  desire  to  study  the  mode  of  action  of  an  emetic  in  your  own 
organism,  there  will  be  no  harm  in  trying  the  experiment  with  this  drug. 
You  may  take  twenty  grains  of  Ipecacuanha  powder,  Pulvis  Ipecacuanha 
(not  Puhris  Ipecacuanha  Compositus],  suspended  in  half  a  tumbler  of 
warm  or  lukewarm  water.  The  dose  may  be  followed  by  one  or  two 
tumblers  of  warm  water,  and  in  the  course  of  ten  minutes  or  a  quarter 
of  an  hour,  you  will  have  an  opportunity  of  studying  the  violent  con- 
traction of  the  muscular  coat  of  the  stomach,  which  will  be  excited  by 
reflex  action  consequent  upon  the  irritating  effect  of  the  Ipecacuanha  upon 
the  afferent  nerve-fibres  of  the  mucous  membrane  of  the  organ.  Ipecac- 
uanha is  one  of  the  most  potent,  and  in  action  on'e  of  the  least  dis- 
agreeable, of  emetic. remedies. 

Congestion  and  inflammation  occur  in  connection  with  other  mucous 
membranes,  as  well  as  those  to  which  I'  have  specially  drawn  your  atten- 
tion. Thus,  the  gall-bladder  and  gall-ducts  may  suffer  congestion,  and 
inflammation  of  the  mucous  membrane  of  the  urinary  bladder,  of  the 
ureters,  and  of  the  pelvis  of  the  kidney  are  unfortunately  frequently  met 
with,  but  these  cannot,  I  regret  to  say,  be  classed  among  slight  ailments, 
and  they  will  come  under  our  consideration  in  another  part  of  the 
course. 

Chilblains. — This  troublesome  and  often  very  painful  affection  is  due 
to  local  changes  in  the  vessels  of  the  skin  of  parts  of  the  body  most 
distant  from  the  large  vessels,  notably  the  fingers  and  toes,  and  occa- 
sionally the  ears  and  nose.  These  parts  are  more  exposed  to  cold  than 
the  rest  of  the  body,  and  to  them  the  blood  will  be  driven  into  the  rami- 
fications of  the  arteries  with  less  force  than  elsewhere.  Anything  that 
retards  the  return  of  the  blood  towards  the  heart,  such  as  the  pressure 
on  the  superficial  veins  by  tight  gloves  or  shoes  or  garters,  increases  the 
tendency  to  chilblains.  On  the  other  hand,  anything  that  promotes  the 
circulation,  large  and  easy  boots  and  gloves  lined  with  wash-leather  or 
other  warm  material,  may  prevent  their  occurrence  in  persons  predis- 
posed to  the  malady. 

Chilblains  seldom  occur  in  the  adult,  and  they  are  far  more  common 
among  ill-fed,  weak  children  than  among  strong  and  healthy  ones.  In- 
sufficient exercise,  especially  in  the  case  of  those,  and  in  towns  they  are 
very  numerous,  who  suffer  from  weak  heart's  action,  sitting  in  cold  rooms 
and  sleeping  in  chilly  bedrooms  favor  the  development  of  chilblains, 
which  are  also  encouraged  by  insufficient  clothing.  Warm  woollen  under- 
garments down  to  the  wrists- and  ankles  often  prevent  the  occurrence  of 
chilblains  in  those  who  have  been  subject  to  them.  Exposure  to  cold, 


TREATMENT  OF  CHILBLAINS,  269 

more  especially  when  the  vessels  of  the  skin  have  been  for  some  time 
previously  subjected  to  pressure,  is  usually  the  immediate  cause  of  an 
attack. 

In  the  capillaries  of  the  affected  skin  the  blood  flows  slowly  and  re- 
mains too  long  in  the  vessels.  The  composition  of  the  stagnant  blood 
is  probably  altered  by  being  too  long  exposed  to  the  influence  of  cold, 
and  in  consequence  does  not  flow  onwards  towards  the  veins.  Soluble 
matters  transude  through  the  walls  of  the  vessels,  and  the  skin  and  sub- 
jacent textures  in  consequence  become  swollen.  The  afferent  nerve- 
fibres  running  with  the  capillaries  are  necessarily  affected,  and  their  action 
becomes  sluggish,  and  the  muscular  fibres  encircling  the  minute  arteries 
soon  undergo  relaxation.  When  the  force  of  the  heart's  action  becomes 
greater,  and  the  activity  of  the  circulation  temporarily  increased,  as 
occurs  after  meals  or  when  the  patient  gets  warm  in  the  evening  or  in 
bed,  a  rush  of  blood  occurs  to  the  extremities.  The  relaxed  arteries  and 
thin  capillaries  become  greatly  distended,  the  temperature  of  the  part 
rising  several  degrees.  The  sensitive  nerves  at  the  same  time  being  dis- 
turbed in  such  a  way  as  to  occasion  the  intense  itghing  and  discomfort 
experienced  by  the  patient. 

In  some  cases  there  is  little  or  no  itching,  but,  Nevertheless,  the  con- 
gested state  of  the  vessels,  and  consequent  soddening  of  the  tissues,  may 
result  in  damage  to  the  cuticle  which  may  be  raised  in  bullse,  which 
soon  rupture,  and  the  formation  of  troublesome  sores,  which  heal  very 
slowly,  and  add  to  the  patient's  suffering.  In  bad  cases  the  skin  around 
the  vesicles  becomes  dark  and  soddened,  and  sloughs  of  considerable 
size  may  be  formed,  which  often  leave  deep  and  bad  ulcers,  requiring  a 
considerable  time  for  healing. 

Treatment. — Chilblains  often  give  rise  to  very  severe  suffering,  and 
are  difficult  to  cure.  Appearing  to  be  a  purely  local  affection,  the  dis- 
ease is  too  often  treated  by  purely  local  measures  only.  In  a  great  many 
instances  it  will,  however,  be  found  that  improvement  in  the  general 
health  and  strength  is  followed  by  a  cessation  of  the  painful  inflamma- 
tion. Tonics,  especially  preparations  of  Bark  and  of  Iron,  should  be 
given.  One  or  two  tablespoon fuls  of  wine  daily  often  effect  great  im- 
provement without  any  local  treatment  whatever,  and  if  this  plan  is 
adopted  early  in  the  winter  season,  the  subjects  of  chilblains  will  some- 
times escape  an  attack. 

Great  care  should  be  taken  to  clothe  all  children  who  are  tortured 
with  chilblains  in  woollen  next  the  skin.  The  rooms  in  which  they  live 
should  be  well  warmed  in  winter,  and  everything  done  to  assist  the  weak 
and  very  likely  slow  circulation.  Gradual  cooling  down  is  likely  to  do 
more  harm  in  the  case  of  those  subject  to  chilblains  than  sudden  ex- 
posure to  cold  for  a  short  time  only. 

Local  Treatment  of  Chilblains. — If  the  skin  is  not  very  tender,  it  may 
be  painted  with  Tincture  of  Iodine,  or  very  gently  smeared  with  a  lini- 
23* 


2/O  BOILS. 

ment  composed  of*  equal  parts  of  Soap  Liniment,  Liniment  urn  Saponis, 
and  Tincture  of  Iodine,  Tinctura  lodi.  Smearing  the  inflamed  skin 
with  a  little  Turpentine,  Oleum  Terebinthince,  or  Acetic  Acid,  Acidum 
Aceticum,  or  the  Liniment  of  Turpentine  and  Acetic  Acid,  Linimentum 
Terebinthince  Aceticum,  or  Camphorated  Spirit,  Spiritus  Camphora, 
undoubtedly  much  relieves  the  itching ;  but  if  the  cuticle  is  tender  or 
sore,  such  remedies  do  harm  instead  of  good.  In  this  case  the  tender 
part  is  to  be  painted  over  with  several  layers  of  Collodion,  or  the  Col- 
lodion flexile,  made  of  Collodion,  Canada  Balsam,  and  Castor-oil.  In 
this  way  a  sort  of  artificial  cuticle  is  made,  by  which  the  tender  parts 
beneath  are  protected  until  they  recover  their  healthy  condition,  and 
time  has  been  allowed  for  the  formation  of  new  cuticular  cells  beneath, 
and  for  the  hardening  process  to  be  carried  out  by  which  the  protective 
property  of  the  cuticle  is  established.  If  the  skin  is  actually  broken,  a 
small  poultice  is  to  be  applied  with  or  without  some  stimulating  substance, 
such  as  Resin  Ointment,  Unguentum  JResince,  or  Peruvian  Balsam,  B'al- 
samum  Peruvianum.  The  health  must  at  the  same  time  be  well  sustained 
by  good  food,  wine,  Quinine,  and  Cod-Liver  Oil.  When  the  sloughing 
process  has  ceased,  a  stimula-ting  zinc  lotion,  one  or  two  grains  to  an 
ounce  of  water,  or  cSrbolic  acid  lotion,  or  one  part  of  absolute  Phenol 
to  forty  parts  of  water,  may  be  used,  or  Lister's  antiseptic  gauze  may  be 
applied. 

Boils,  although  brought  about  by  very  different  circumstances,  some 
unimportant,  others  indicative  of  grave  disease,  may  be  fairly  included 
among  "slight  ailments."  The  old  name  for  boil  is  Furunculus. 

This  affection  played  a  more  formidable  part  during  and  anterior  to 
the  middle  ages  than  since  and  than  it  does  now.  In  former  days  many 
very  serious  and  fatal  febrile  conditions  were  characterized  by  the  for- 
mation of  boils.  Although  in  these  days  boils  may  be  associated  with 
certain  forms  of  blood-poisoning,  usually  fatal,  they  are  much  more 
common  in  states  of  the  system  due  to  temporary  derangement  of  the 
blood  than  they  are  in  serious  blood  diseases  which  soon  destroy  life. 

Pathologically  the  boil  is  of  great  interest,  as  the  inflammation  begins 
in  one  spot  and  quickly  involves  a  number  of  tissues,  including  nerves, 
blood-vessels,  and  lymphatics,  as  well  as  all  the  textures  forming  the  true 
skin.  A  small  portion  of  the  complex  tissue  is  destroyed,  in  fact  it  dies, 
.  and  is  cast  off  as  a  slough  of  dead  decomposing  tissue,  the  removal  of 
which  is  soon  followed  by  the  healing  process. 

The  local  inflammation  thus  ending  in  mortification  and  removal  of 
a  portion  of  the  skin  and  subjacent  structures,  starts  from  within.  It  is 
difficult  to  decide  whether  the  local  change  begins  in  a  capillary  or 
lymphatic  vessel ;  but  in  most  cases  it  is  probably  in  the  capillary,  which 
is  the  seat  of  the  changes  which  result  in  the  formation  of  the  boil. 
Particles,  probably  of  living  matter,  adhere  to  the  wall  of  the  capillary, 
and  grow  and  multiply  until  the  vessel  is  occluded  partly  by  accumulation 


TREATMENT  OF  BOILS. 

of  matter  caused  by  the  growth  and  multiplication  of  these  tiny  particles, 
and  partly  by  fibrin  from  the  blood.  The  capillary  being  thus  plugged, 
exudation  takes  place  from  the  adjacent  capillary  vessels;  and  with  the 
fluid  poured  out  minute  particles  of  living  matter  also  escape,  and  these 
multiply  in  the  surrounding  tissue.  In  this  way  the  ordinary  nutrition 
of  the  part  suffers,  and  the  usual  flow  of  fluid  to  and  from  the  living  mat- 
ter of  the  several  tissues  which  takes  place  in  health  is  stopped.  The 
nerves  of  the  capillaries  and  other  parts  are  stretched  and  pressed  upon 
in  consequence,  and  considerable  pain  is  experienced.  The  rapid  growth 
and  multiplication  of  living  matter,  which  occurs  in  every  part  of  the 
affected  region,  as  usual  is  associated  with  the  increased  development  of 
heat.  The  inflamed  tissues  constituting  the  boil  are  sensibly  warmer 
than  the  surrounding  healthy  tissues. 

A  certain  amount  of  pus  is  formed  between  the  core  of  dead  tissue  and 
the  surrounding  healthy  structures.  By  this  process  the  disintegration 
of  the  affected  tissues  is  assisted,  and  the  separation  of  the  slough  of  dead 
tissue  from  the  surrounding  healthy  part  is  expedited. 

Boils  may  be  caused  by  a  poison  developed  within  the  system  or  in- 
troduced into  the  blood  from  without.  The  inhalation  of  infected  air, 
eating  diseased  meat,  over-eating,  insufficient  and11  bad  food,  too  much 
animal  food,  may  establish  a  state  of  health  favorable  to  the  formation  of 
boils.  An  actual  alteration,  no  doubt,  takes  place  in  the  blood,  although 
it  is  not  possible  to  determine  its  exact  nature.  Boils  are  liable  to  occur 
after  recovery  or  partial  recovery  from  fevers,  and  are  very  common  in 
cases  of  diabetes;  but  the  precise  influence  exerted  by  the  diabetic  state 
upon  the  tissue,  which  results  in  the  development  of  the  boil,  has  not  yet 
been  ascertained.  The  bites  of  mosquitos,  if  numerous,  may  occasion 
blood-poisoning  and  considerable  derangement  of  the  health,  lasting  for 
a  considerable  time,  and  ending  in  the  formation  of  boils  of  an  obstinate 
kind  in  different  parts  of  the  body. 

Carbuncle,  Anthrax,  is  closely  allied  to  boils,  but  is  more  serious  from 
the  much  larger  area  and  depth  of  the  inflamed  tissue,  and  from  the  more 
serious  constitutional  disturbance.  The  inflammation  is  more  diffused  ; 
the  slough  formed  is  often  so  very  large  that  the  patient's  strength  is 
exhausted  before  its  separation  is  effected,  and  the  reparative  process  can 
begin.  This  affection  cannot  properly  be  included  among  "slight  ail- 
ments," and  I  therefore  only  refer  to  it  as  a  farther  development  of  the 
boil. 

Treatment. — As  regards  the  treatment  of  boils,  the  best  advice  I  can 
give  you  is  to  leave  them  alone.  Incisions  are  not  needed,  and  any  at- 
tempt to  expedite  the  removal  of  the  slough  does  harm  by  breaking  down 
the  temporary  separation  between  the  slough  and  the  healthy  tissue,  thus 
causing  some  of  the  irritating  discharge  to  pass  into  the  surrounding 
areolar  tissue,  starting  therein  a  similar  inflammatory  action  leading  to 
sloughing  over  a  wider  area.  It  is  important,  however,  to  prevent  the 


272  CHANGES  PREPARATORY 

boil  from  being  rubbed  or  pressed  upon  by  the  clothes.  A  small  piece 
of  thick  Amadou  plaster-like  felt  may  be  taken,  and  a  hole  cut  large 
enough  to  receive  the  boil,  the  summit  of  which  may  be  partially  cov- 
ered by  a  piece  of  ordinary  plaster.  Yeast  has  been  highly  recommended 
internally,  but  its  efficacy  is  doubtful.  Quinine,  mineral  acids,  and  ton- 
ics of  various  kinds  seem  to  be  useful.  Wine  may  be  given  in  the  case 
of  patients  whose  strength  has  been  worn  out  by  prolonged  exhausting 
disease,  but  in  ordinary  cases  more  harm  than  good  results  from  stimu- 
lants. 

It  has  been  remarked  several  times,  in  these  introductory  lectures  on 
Slight  Ailments,  that  illnesses  which  apparently  come  on  suddenly  are 
themselves  but  the  consequence  of  prior  changes  which  have  been  going 
on  for  some  time  previous  to  the  attack.  These  preliminary  changes  are 
a  necessary  and  essential  part  of  the  illness,  and,  but  for  them,  the  attack 
could  not  have  occurred.  The  invasion,  it  is  true,  seems  to  be  sudden, 
but  the  apparently  rapid  passage  from  comparative  health  to  decided  ill- 
ness is  deceptive,  for  derangement  even  of  a  serious  character  has  cer- 
tainly existed  for  some  time,  though  the  patient  may  not  have  been  aware 
of  it.  In  many  cases  very  great  disturbance  only  gives  rise  to  mere  dis- 
comfort, and  the  patient  himself  can  form  no  conception  of  the  serious 
changes  which  are  going  on  in  his  tissues.  In  not  a  few  instances,  espe- 
cially persons  about  or  past  the  middle  period  of  life,  the  nerves  are  more 
or  less  numbed  owing  to  structural  changes  in  them.  They  do  *ot  re- 
spond as  readily  as  they  should  do,  and  in  consequence  their  owner  does 
not  experience  the  pain  and  discomfort  which  ought  to  warn  him  of  the 
occurrence  of  derangement  in  action  or  alteration  in  structure. 

By  paying  attention  to  the  signs  and  symptoms  of  derangements  which 
may  be  correctly  termed  slight,  and  relieving  them  as  soon  as  possible, 
we  may  succeed  in  preventing  the  occurrence  of  grave  pathological 
changes.  You  will  remark  that  many  persons  who  will  tell  you  they 
do  not  know  what  it  is  to  feel  well,  have  not  in  the  whole  course  of  their 
lives  once  been  seriously  ill,  and  such  lives  you  will  often  find  will  be 
exceptionally  long.  The  nerves  are  sound,  and  their  peripheral  ramifi- 
cations in  a  healthy  and  highly  sensitive  condition,  so  that  the  slightest 
change  in  their  neighborhood  is  made  evident  to  their  owner  by  pain 
and  discomfort,  or  by  some  form  of  nerve  disturbance.  The  man  who 
experiences  slight  derangements  of  health  oftentimes  takes  steps  to  re- 
lieve his  discomfort,  and,  by  acting  thus,  very  likely  succeeds  in  remov- 
ing the  condition  which  precedes  the  development  of  actual  disease.  It 
is  also  probable  that  the  very  means  taken  to  remove  slight  symptoms 
are  also  effective  in  bringing  about  a  state  of  the  system  which  is  not 
favorable  to  the  development  of  severe  illness,  or  the  invasion  of  mor- 
bid poisons.  It  would  seem  as  if  some  preparatory  changes  were  neces- 
sary to  render  the  organism  fitted  either  for  the  reception  of  morbid 


TO    THE    OCCURRENCE    OF  DISEASE.  273 

poisons,  or  for  the  initiation  of  the  majority  of  morbid  changes  in  tis- 
sues and  organs.  Even  in  the  case  of  many  purely  local  lesions  it  is 
probable  that,  for  some  considerable  time  before  any  actual  structural 
change  has  occurred,  there  have  been  congestion  and  disturbed  action. 
But  for  the  persistence  of  these,  the  local  disease  would  not  have  mani- 
fested itself.  How  important  it  is,  therefore,  that  we  should  search  for 
evidence  of  preliminary  change,  in  order  that,  by  altering  the  conditions 
of  life  for  a  time,  by  relieving  local  congestion,  by  promoting  excretion, 
or  by  establishing  some  increased  local  action,  we  may  succeed  in  bring- 
ing about  a  return  to  physiological  health  before  any  of  those  grave 
morbid  conditions,  which  will  occupy  much  of  our  attention  in  this 
course  of  lectures  on  the  Principles  and  Practice  of  Medicine,  can  be 
established. 

I  have  already  drawn  your  attention  to  the  preliminary  changes,  which 
occur  in  the  conjunctiva  and  glands  connected  with  it,  by  which  it  be- 
comes fitted  for  the  reception  and  propagation  of  the  minute  particle  of 
that  specific  and  poisonous  bioplasm  which  is  concerned  in  the  develop- 
ment of  a  most  formidable  and  destructive  kind  of  inflammation.  Al- 
though, undoubtedly,  there  are  a  few  living  poisons  which  are  so  virulent 
in  their  properties,  and  have  such  extraordinary  power'  of  vitality  that 
almost  every  one  exposed  to  their  influence  is  attacked  with  the  disease 
they  engender,  this  is  so  decidedly  exceptional  that  one  may  fairly  ven- 
ture to  advance  the  conclusion  that  it  is  at  least  conceivable  that  indi- 
vidual human  or  animal  organisms  may  exist,  upon  which  the  great  ma- 
jority of  contagious  poisons  known  to  invade  might  beat  in  vain.  And, 
as  time  goes  on,  I  think  I  shall  convince  you  that  the  prospect  of  our 
being  'successful  in  discovering  the  means  of  enabling  the  individual 
organism  to  resist  the  assaults  of  contagion  is  far  brighter  than  that  of 
our  discovering  how  to  exterminate  contagion  itself,  and  to  prevent  new 
forms  of  contagious  living  matter  from  springing  into  life. 

The  poison  instrumental  in  carrying  ophthalmia  undoubtedly  spares 
some  exposed  to  its  influence,  and,  amongst  those  attacked,  varying 
degrees  of  severity  of  the  disease  will  be  observed v  Even  ringworm, 
and  many  other  diseases  invariably  associated  with  the  growth  and  mul- 
tiplication of  a  special  vegetable  organism,  will  not  invade  every  indi- 
vidual indiscriminately,  and  those  who  have  been  long  under  bad  influence 
as  regards  bodily  health,  are  sure  to  be  the  first  attacked,  and  to  suffer 
most  severely  and  for  the  longest  time  from  the  disease.  Of  a  number 
of  persons  swallowing  the  poison  of  typhoid,  or  exposed  for  the  same 
period  of  time  to  its  baneful  influence,  some  will  escape  altogether,  some 
will  be  violently  assaulted  by  the  poison,  but  will  escape  without  the 
specific  disease  being  developed  in  consequence  of  a  sharp  attack  of 
diarrhoea,  some  will  pass  through  a  mild  form  of  the  disease,  and  a  small 
number  will  be  severely  attacked,  of  which  perhaps  one-eighth  will  be 
destroyed  by  the  fever  or  its  consequences. 

S 


2/4     CHANGES  PREPARATORY  TO  OCCURRENCE   OF  DISEASE. 

So,  too,  with  regard  to  acute  inflammations  and  various  diseases  of  a 
non-contagious  character,  what  seems  to  be  a  sudden  illness  is  probably 
but  the  climax  of  a  series  of  changes  which  have  been  going  on  for  a 
considerable  time,  although  the  patient  may  not  have  been  aware  that 
anything  was  wrong.  An  attack  of  acute  rheumatism  is  always  referred 
to  exposure  to  wet  and  cold,  or  to  sleeping  in  a  damp  bed,  or  to  a  long 
drive  or  walk  in  the  rain,  or  to  some  single  unfortunate  circumstance  or 
want  of  caution  on  the  part  of  the  patient.  But  how  many  of  us  are 
exposed,  over  and  over  again,  to  adverse  conditions  of  precisely  the  same 
kind  with  perfect  impunity.  The  peculiar  state  of  the  blood  which  pre- 
cedes the  attack  of  illness,  and  which  alone  renders  the  attack  possible, 
has  been  produced  after  a  prolonged  course  of  pathological  changes. 
But  if  this  special  state  of  blood  exists  not,  instead  of  the  person  ex- 
posed to  the  adverse  influences  being  attacked  by  acute  rheumatism  or 
pneumonia,  or  pleurisy,  or  some  other  acute  inflammation,  he  experiences, 
perhaps,  a  sharp  rigor,  accompanied  possibly  by  local  pain  and  general 
discomfort,  succeeded  in  two  or  three  hours  by  profuse  sweating,  prob- 
ably diarrhoea,  and  the  secretion  of  urine  rich  in  urates,  uric  acid,  and 
other  matters.  In  the  course  of  a  day  or  two,  except  feeling  a  little 
weak,  the  patient  regains  his  normal  state  of  health.  Perhaps,  indeed, 
for  some  time  afterwards  he  may  even  feel  exceptionally  well  and  vigor- 
ous. He  has,  in  fact,  been  relieved  by  the  removal  of  various  substances 
which  had  been  for  some  time  accumulating  in  his  blood  to  his  detriment, 
and  which  at  any  moment  might  have  been  instrumental  in  the  develop- 
ment of  local  disease  in  some  important  organ.  These  considerations, 
supported  by  many  more  to  which  I  might  advert,  suggest  the  general* 
conclusion  that  the  maintenance  of  each  individual  organism  in  a  good 
state  of  health,  the  careful  attention  on  the  part  of  the  practitioner  to 
slight  ailments,  and  the  recognition  by  hini  of  any  symptoms  that  may 
indicate  slight  derangement  of  function  or  action,  are  of  far  greater  con- 
sequence than  the  hunting  after  and  extermination  of  various  species  of 
hypothetical  pathological  organisms,  even  though  it  were  actually  possible 
to  catch  and  exterminate  legions.  9 

I  believe  that  if  the  organism  be  in  a  proper  state,  almost  all  disease 
germs  coming  in  contact  with  it,  or  entering  it,  will  certainly  die,  instead 
of  growing  and  multiplying  and  deranging  or  destroying  important  con- 
stituents of  the  blood  and  tissues.  Many  of  the  poisons  in  question  are 
round  about  us — in  the  food  we  eat — in  the  water  we  drink.  The  foot 
of  a  fly  will  carry  enough  poisonous  matter  to  infect  a  household.  It  is, 
therefore,  vain  to  be  always  seeking  to  annihilate  contagion  which  you 
can  only  destroy  to  a  most  limited  and  probably  useless  extent.  On  the 
other  hand,  it  seems  exceedingly  reasonable,  and  especially  on  the  part 
of  nurses  and  ourselves,  who  must  be  continually  exposed  to  the  assaults  of 
disease  germs,  to  do  all  that  is  possible  to  promote  and  improve  the  resist- 
ing power  of  the  body.  We  always  notice  that  of  those  exposed  to  the 


SLIGHT  DERANGEMENTS  PREVENTING  SERIOUS' DISEASE.    2?$ 

same  adverse  conditions,  but  a  very  small  percentage  will  be  seriously  ill. 
A  moderate  number  only  after  suffering  exposure  will  catch  cold  or  ex- 
perience some  slight  derangement.  The  majority  will  entirely  escape. 
No  doubt  such  facts  may,  in  part,  be  explained  on  the  supposition  of  the 
existence  of  difference  in  constitution  in  the  different  individuals.  Allow- 
ing amply  for  this,  however,  there  is  good  ground  for  concluding  that  it 
is  possible  to  preserve  the  body  in  such  a  state  of  health  as  would  enable 
it  to  resist  attacks  of  contagious  poisons,  to  any  one  of  which,  in  a  dif- 
ferent condition,  it  would  certainly  succumb.  In  other  words,  there  is 
good  reason  for  the  conclusion  that  it  is  possible  to  resist  the  onslaught 
of  contagious  poisons,  and,  therefore,  that  it  is  possible  to  still  increase 
the  health  of  the  community.  By  detecting  and  treating  slight  derange- 
ments, I  have  no  doubt  whatever  that  we  frequently  succeed  in  establish- 
ing a  state  of  the  system  which  renders  the  supervention  of  serious  disease 
almost  impossible. 

The  comparative  immunity  of  those  who  are  frequently  troubled  with 
various  slight  derangements  of  health  has  been  frequently  noticed.  Per- 
haps it  is  to  be  explained  by  the  existence,  in  particular  individuals,  of 
a  highly  sensitive  and  exceptionally  active  state  of  those  nerve-fibres, 
and  that  part  of  the  nervous  system  which  is  intimately  connected  with 
the  healthy  action  of  the  circulating  and  digestive  systems.  In  some 
persons  these  nerves  respond  to  the  slighest  stimulus,  and  the  least  de- 
parture from  the  ordinary  state  at  once  occasions  inconvenience  or  dis- 
comfort ;  while  in  others,  considerable  variation,  as  regards  temperature, 
quality  and  quantity  of  food,  make  little  or  no  impression,  and  occasion 
*no  immediate  disturbance  or  derangement.  But,  in  the  latter  case, 
pathological  changes  may  take  place,  and  may  result  in  grave  structural 
alteration,  without  the  patient  having  experienced  the  least  discomfort, 
or  even  being  made  aware  that  any  departure  from  health  had  occurred 
in  his  system  before  the  supervention  of  the  serious  illness  which  you 
are  asked  to  investigate  and  treat.  Perhaps,  in  some  such  manner,  we 
may  attempt  to  account  for  the  fact  that  certain  individuals  are  suddenly 
struck  down  by  terrible  disease  while  they  seem  to  be  in  good  health, 
and  others,  who  never  feel  well,  or  look  well,  reach  old  age  without  ex- 
periencing one  single  attack  of  any  illness  so  serious  as  to  endanger  life. 
Such  persons,  it  must  be  noted,  are  often  obliged  to  be  very  careful,  as 
regards  diet,  and  the  feeling  of  tiredness,  after  great  exertion,  is  in  them 
so  distinct  that  it  must  be  yielded  to.  Thus  they  are  forced  to  take  rest 
before  any  damage  whatever  has  been  done  to  their  organs.  It  is  not 
probable  that  careful  attention  to  the  process  of  excretion,  as  well  as  to 
the  quality  and  quantity  of  food  that  is  taken,  brings  about  and  preserves 
a  state  of  blood  in  which  disease  germs,  instead  of  growing  and  multi- 
plying, would  die?  How  many  ailments  may  not  be  prevented  by  judi- 
cious starving,  or  by  living  for  a  day  or  two  now  and  then  on  low  diet  ? 
How  thoroughly  may  not  the  blood  be  depurated  by  a  sharp  purge  given, 


27-6  •-.•.£.'•  CONCLUSION. 

perhaps,  just  before  liquor  sanguinis  was  about  to  escape  from  the  vessels, 
to  be  poured,  perhaps,  into  the  air-cells  of  the  lung?  Might  not  the 
purgation  be  fairly  considered  to  have  prevented  an  impending  attack  of 
acute  Pneumonia  or  Inflammation  of  the  Lung,  and  thus  to  have  really  "cut 
short"  the  disease?  May  not  moderate  doses  of  Bicarbonate  of  Potash 
or  Soda,  taken  in  solution  twice  or  three  times  a  day  for  a  week  or  two, 
avert  an  attack  of  acute  rheumatism?  Will  not  a  small  dose  of  certain 
preparations  of  Mercury,  now  and  then,  prevent  attacks  of  gout  or  rheu- 
matism or  sick  headache  or  dyspepsia  or  biliousness  ?  Is  it  not  reason- 
able to  conclude  that  certain  salts,  by  their  action  on  the  bowels  and 
kidneys,  by  promoting  free  elimination,  establish  a  general  state  of  the 
tissues,  which  may  for  the  time  render  it  impossible  that  certain  morbid 
changes  of  serious  consequence  should  occur  ? 

I  have  endeavored,  in  these  few  lectures,  to  show  you  why  we  should 
not  fail  to  devote  some  attention  to  the  study  of  those  slight  departures 
from  the  normal  state  which  possibly,  in  these  days,  are  sometimes 
passed  over  by  the  practitioner,  although,  on  the  one  hand,  their  import 
may  be  strangely  exaggerated,  or,  on  the  other,  hardly  noticed  by  the 
patient  himself.  As  I  have  tried  to  impress  upon  you  many  times,  slight 
derangements  sometimes  afford  the  first  and  only  indications  of  com- 
mencing disease  of  a  serious  character.  There  is  good  reason  for  think- 
ing that  by  judicious  management,  not  only  may  some  troublesome 
though  slight  ailments  be  entirely  relieved,  but  further  and  progressive 
morbid  changes  may  be  prevented  or  retarded. 

The  principles  upon  which  the  treatment  of  many  slight  ailments  may" 
be  successfully  conducted,  are  the  same  as  those  upon  which  the  manage- 
ment of  more  marked  developments  of  morbid  phenomena  is  based.  I 
have  given  illustrations  of  the  simplest  and  slightest  ailments,  and  have 
endeavored  to  show  how  their  treatment  may.be  most  simply  and  suc- 
cessfully carried  out,  and  I  have  attempted  to  lead  you  on  by  degrees  to 
consider  more  highly  complex  pathological  changes,  and  to  explain  the 
principles  upon  which  more  complex  methods  of  treatment  are  based. 
In  no  way,  I  believe,  can  you  so  quickly  acquire  that  sound  knowledge 
of  pathological  processes,  and  of  the  means  of  checking  or  modifying 
them,  which  are  daily  required  in  practice,  as  by  adopting  the  course  I 
have  advocated.  Let  me,  therefore,  conclude  by  again  impressing  upon 
you  the  importance  of  not  neglecting  the  study  of  the  nature  and  treat- 
ment of  "  Slight  Ailments"  now,  or  at  any  period  of  your  professional 
career. 


INDEX. 


A  BSORPTION  of  fluid  in  constipation, 

I\     117- 

Acid  application  to  liver,  167. 

drinks  in  sick  headache,  179. 

eructations,  147. 

of  the  stomach,  95. 

Action,  increased,  its  effects  in  treatment, 

253- 

Acute  Jaundice,  166. 

Afferent  nerves  of  capillaries,  235. 

Ague  fit,  212. 

Ailments  beginning  like  a  cold,  203. 

Air-passages,  inflammation  of,  264. 

Albuminous  matters,  effects  of  alcohol  on, 

256. 
Alcohol,  bad  effects  of,  81. 

causing  vertigo,  156. 

•          in  dyspepsia,  8l. 

its  use  in   the   treatment  of  fissures 

and  ulcerations,  255. 
Alkalies  in  rheumatism,  198. 
Aloes  in  cases  of  offensive  breath,  74. 
— —  preparations  of,  in  constipation,  138. 
_Alum  as  a  gargle,  263. 

spray  in  sore  throat,  69. 

Ammonia,  chloride  of,  191. 

Amoeba,  251. 

Anaemia,  state  of  tongue  in,  62. 

Anorexia,  75. 

Anthrax,  271. 

Appetite,  impaired,  75. 

•  voracious,  77. 

Apples  in  constipation,  128. 

Aphthae,  70. 

Ardor  ventriculi,  90. 

Area  of  redness  in  flea-bite,  225. 

Arsenic,  191. 

Arteries,  alteration  of,  in  flea-bite,  225. 

Artery  with  nerve-fibres  distributed  to  it, 

227,  230. 

Artificial  teeth,  value  in  dyspepsia,  101. 
Ascarides,  154. 
Ascaris  lumbricoides,  154. 
Astringents  in  ophthalmia,  260. 

. in  the  treatment  of  diarrhcea,  151. 

• in  the  treatment  of  piles,  122. 

Aural  vertigo,  157. 

BACTERIA  in  blood  in  health;  50. 
as  a  cause  of  disease,  51. 

• in  intestine  of  infant,  49. 

Balsam,  Peruvian,  270. 
Baptistin,  163. 

24 


Bat's  wing,  nerves  to,  233. 
Beef-tea,  peptonized,  109. 
Bilious  diarrhoea,  150. 
Biliousness,  157. 

treatment  of,  161. 

Bioplasm   changes  in  outside  capillaries, 

247- 

growth  of,  in  inflammation,  222. 

minute  particles  in  blood,  245. 

Bite,  flea,  222. 

gnat,  237. 

Black  tongue,  64. 

Blood  in  fever  and  inflammation,  221. 

filaria  in,  144. 

in  constipation,  121. 

passing  through  vessels  in  fever,  222. 

state  of,  in  sick  headache,  171. 


Blue  pill  in  biliousness,  161. 
Body-heat  in  fever,  222.' 

in  man  and  animals,  206. 


Borax  and  honey  for  thrush,  71. 

Borborygmi,  93. 

Brain,  overworking,  188. 

-  and  stomach,  155. 

Bread,  127. 

Breath,  odor  of,  72. 

Bright  red  tongue,  63. 

Bromide  of  potassium  in  rheumatism,  199. 

Bronchitis  kettle,  68. 

Brow  ague,  168. 

Brown  bread,  113,  127. 

Bulimia,  78. 


affected  in  sick  headache,  171. 
V_,     Calibre  of  small  artery,  maintenance 

of,  at  a  given  point,  227. 
Calomel  in  dyspepsia,  93. 

-  effect  on  secretion  of  saliva,  61. 
Camphorated  spirits  in  the  treatment  of 

chilblains,  270. 
Capillaries  in  flea-bite,  225. 

-  in  inflammation,  222. 

-  passage  of  corpuscles  through  walls 
of,  240. 

Capillary  haemorrhage,  224. 

-  capillary  vessels,  nerves  of,  230. 
Carbolic  acid  as  a  gargle,  69. 

-  in  cases  of  offensive  breath,  73. 
Carbuncle,  271. 

Cardialgia,  90. 

Carlsbad  water,  143. 

Castor.  oil  for  constipation,  135. 

-  for  diarrhoea,  146. 

277 


2/8 


INDEX. 


Catarrh,  214. 

Catarrhal  inflammation  of  stomach,  266. 

Catching  cold,  202. 

Catechu,  151. 

Cayenne  pepper  in  nausea,  86. 

Cells,  changes  in  epithelial,  in  a  flea-bite, 
222. 

of  liver  in  biliousness,  1 60. 

Chaff,  113. 

Chalk  mixture,  152. 

Changes,  minute,  in  fever  and  inflamma- 
tion, 219. 

Charcoal  powder  in  cases  of  offensive 
breath,  72,  73. 

Cheltenham  water,  142. 

Chilblains,  268. 

Children,  constipation  in,  120. 

high  temperature  in  slight  ailments, 

217. 

Chlorate  of  potash  in  sore  throat,  69. 

as  a  gargle,  263. 

Chloride  of  sodium  in  sore  throat,  69. 

Chloral  hydrate,  192. 

its  dangers,  186. 

Chlorodyne,  94. 
Cholera,  145,  211. 

Chronic  rheumatism,  treatment  of,  196. 
Citrate  of  magnesia,  143. 
Circulation,  intermolecular,  39. 

capillary,  mechanism  for  governing, 

232. 

Civilization,  slight  ailments,  1 8. 

Clothing,  warm,  importance  of,  99. 

Cleaning  of  tongue,  65. 

Clinical  thermometer,  209. 

Clyster,  123. 

Coffee  in  constipation,  128,  135. 

COHNHEIM,  on  migration  of  blood  cor- 
puscles, 243. 

Cold  bath  in  constipation,  125. 

catching,  202. 

causing  a  febrile  attack,  221. 

influence  of,  on  blood  and  tissues,22l. 

its  influence  in  diarrhoea,  149. 

sick  headache,  1/8. 

stage  in  fever,  210. 

treated  by  counter-irritation,  253. 

treatment  of  a,  214. 

Collodion,  270. 

Colon,  tenderness  of,  149. 

Color  of  the  tongue,  42. 

Complexion  in  those  who  suffer  from  con- 
stipation, 1 18. 

Condiments,  97. 

CONDY'S  fluid,  gargle  of,  65. 

in  offensive  breath,  73. 

Congestion  of  capillaries  in  flea-bite,  224. 

of  mucous  membrane  of  bowel,  267. 

Conjunctiva,  inflammation  of,  256. 

Connective-tissue  formed-  by  bioplasm, 
247. 

Constipation,  in. 

in  jaundice,  165. 

in  sick  headache,  171. 

• treatment  of,  109,  131. 


Contagion,  275. 

Contagious  disease,  46. 

Contractile  power  of  bowel,  loss  ot',  116. 

Contraction  of  minute  arteries,  228. 

Co-ordinating  power  in  vertigo,  156. 

Corpuscles,  mucus,  250. 

blood,     passage     through    vascular 

walls,  241. 
outside   capillaries  in  inflammation, 

244. 

Coryza,  214. 
Counter-irritation,  253. 

in  sick  headache,  178. 

in  stomach,  266. 

Cracks  and  fissures  of  tongue,  65. 

on  lips,  254. 

Critics  subject  to  constipation,  115. 
Croakings,  flatulent,  93. 
Croton-chloral-hydrate,  192. 

oil  in  constipation,  140. 

Croupous  membrane,  264. 
Curry  powder  in  nausea,  80. 
in  dyspepsia,  97. 

DEATH-carrying  bacteria,  54. 
Decay,  part  played  in  by  fungi,  44. 
Decillionths  of  grains,  29. 
Degeneration  of  muscles  in  rheumatism, 

196. 

Demonstrating  nerves  distributed  to  cap- 
illaries, 232. 

Deranged  action  of  glandular  organs,  89. 
Diabetes,  77. 

causing  boils,  271. 

Diagnosis,  importance  of  being  cautious 

in  making,  217. 
Diapeclesis,  240,  243. 
Diarrhoea,  144. 

treatment  of,  151. 

Diathesis,  76. 

Diet  in  constipation,  127. 

in  rheumatism,  211. 

in  diarrhoea,  150. 

in  hot  and  cold  climates,  98. 

in  indigestion,  93.  . 

Digestion,  artificial,  109. 

—  in  jaundice,  167. 

—  non-nutritious  matters  in,  113. 

—  in  rheumatism,  205. 
Digestion  in  sick  headache,  169. 
Dilatation  of  capillary  vessels  in  fever  and 

inflammation,  222,  232. 
Diluents  in  a  cold,  218. 
Diphtheria,  261. 
Disease  germs,  275. 
Disks  for  hypodermic  injection,  192. 
Dispensaries,  self-supporting,  35. 
Dissection  of  nerves  of  intestines,  87. 
Diuretics  in  a  cold,  215. 
Dorsum  of  tongue,  43. 
Douche,  eye,  260. 
Dover's  powder,  191. 
Dried  apples  in  constipation,  129. 
Drowsiness,  184. 
Dry  mouth  and  fauces,  67. 


INDEX. 


279 


Dry  tongue,  58. 

brown  tongue,  63. 

Dust  and  disease,  50. 
Dysentery,  267. 
Dyspepsia,  84. 
treatment  of,  94. 

EAST  wind  causing  biliousness,  162. 
Eau   de  Cologne    in    treatment  of 

cracks  and  fissures  of  lips,  255. 
Efferent  nerves  to  arteries,  236. 
Effervescing  citrate  of  magnesia,  143 

saline  purgatives,  143. 

Elaterium  in  constipation,  140. 

Emetics,  92,  268. 

Empirical  treatment,  267. 

Endurance,   powers   of,  in  sufferers  from 

sick  headache,  172. 
Enemata,  action  of,  123. 
Epilepsy  and  sick  headache,  174. 
Epithelial  cells  of  tongue,  43,  44,  45. 
Epithelium,  irregular  growth  of,  254. 

pus  formed  in,  224. 

Epsom  salts,  141. 

Eructations,  acid,  147. 

Eruption  in  fever,  221. 

Eruptions,  252. 

Examining  mucus-corpuscle,  249. 

Excess  of  urea,  208. 

Ex  oriations,  treatment  of,  255. 

Excretion,  importance  of,  204. 

Exercise  in  constipation,  125. 

External  applications  in  indigestion,  96. 

Exudation,  241. 

in  fever  and  inflammation,  222. 

in  rheumatism,  195. 

Eye-glass,  259. 
Eye  waters,  259. 

T7/ECAL  matter,  impaction  of,  116. 
1      False  membrane,  264. 
Fasting  girls,  77. 
Fauces,  dryness  of,  67. 
Febrile  diseases,  203. 
Fever,  local,  222. 

and  inflammation,  207,  219. 

Feverish  and  inflammatory  state,  202. 
Feverishness    produced    by   irritation   of 

stomach,  146. 

Feverishness,  secretion  in,  213. 
Fevers,  formation  of  pus  in,  239. 
Fibrin,  bacteria  in,  50. 
Fibrous  matter,  formed  from  bioplasts,  247. 
Filaria  sanguinis  hominis,  238. 
Filiform  papillae,  43. 
Fissures  and  cracks  of  tongue,  65. 
Flannel  for  warm  clothing,  99. 
Flatulence,  92. 
Flea-bite,  222. 
Fluid,  quantity  of,  to  be  taken,  83. 

—  importance  of  taking,  in  constipation, 

117,  129 

Fog,  its  effects  on  conjunctiva,  256. 
Food,  abstention  from,  in  sick  headache, 

177- 


Food,  importance  of  not  taking  too  much, 

19,  79- 

Fountain,  eye,  260. 

FOWLER,  DR.,  his  case  of  the  fasting  girl, 

77- 

Friedrichshall  water,  142. 
Fruit  causing  diarrhoea,  145. 

in  constipation,  128. 

Fungi,  germs  of,  45. 

growth  and  multiplication  of,  45. 

on  tongue,  44. 

Fungi  form  papillae,  43. 
Furred  tongue,  6l. 
Furunculus,  270. 

f~^  ALL  stones,  166. 

\J     Gamboge,  140. 

Ganglia,"  89. 

regulating  calibre  of  small  arteries 

227. 

Gargles,  263. 

Gastric  glands,  nerves  of,  87. 
Gastralgia,  89. 

Gastric  juice,  variation  in  quantity  of,  57. 
Gastrodynia,  89. 

General  changes  from  local  injury,  237. 
Germs  o*  fungi,  4.4. 
in  every  part  of  body,  48. 

—  on  tongue,  44. 
G  Jdiness,  154. 

Glands  o<  conjunctiva,  inflamed,  257. 
exciting  action  of,  in  offensive  Dreath, 

73- 

gastric,  wasting  of,  100. 

Glauber  salts,  141. 

Glycerine  and  water,  64. 

Gn.u-bite,  changes  resulting  from,  237. 

Gout  and  sick  headache,  174. 

Granulated  effervescing  salines,  143. 

Gravedo,  214. 

Gray  powder,  61,  70,  102,  167,  176. 

Growth  of  fungi,  47. 

Guarana  in  sick  headache,  181. 

Guiacum  in  rheumatism,  199. 

TT HEMORRHAGE,  65. 

11     capillary,  224. 

Haemorrhoids  or  piles,  120. 

Hair-like  processes  of  papillae  of  tongue, 

44- 

HALLIER  on  fungi,  53. 
Headache,  treatment  of,  175. 

sick,  167. 

Healing  process  disturbed  in  constipation, 

119. 

Healthy  individuals  rare,  19. 
Heartburn,  90. 
Heat  of  body,  206.  » 

in  fever,  206. 

Hemicrania,  1 68. 

Homoeopaths,  28. 

Honey  and  borax  in  aphthae,  Jl. 

Horse  radish.  60. 

Hospital,  out-patients,  36. 

Hot  climates,  diet  in,  97. 


280 


INDEX. 


Hot  stage  in  fever,  210. 

water,  India-rubber  bottle  for,  151. 

Humbug,  medical,  26. 
Hunyadi  Janos  water,  143. 
Hydrocyanic  acid  in  nausea,  85. 
Hygienic  treatment  of  constipation,  125. 
Hypodermic  injection,  186, 191. 
Hyposulphite  of  soda,  65. 
Hydrochloric   acid,   external    application 

of,  to  liver,  167. 

Hydrocyanic  acid,  its  effects,  24. 
Hy!a,  nerve-cells  of,  228. 

artery  of,  228. 

Hysterical  loss  of  appetite,  76. 

IMMUNITY  to  severe  disease  of  those 
J    suffering  from  slight  ailments,  275. 
Impaction  o   fsecal  matter,  116. 
India-rubber  bottle  for  hot  water,  151. 
Indian  corn  flour,  127. 
Indigestion,  84. 
in  old  age,  loo. 

—  re-u'ting  from  loss  of  teeth,  loo. 
treatment  of,  94. 

warm  clothing  in,  100. 

Infant,  growth  of  fungi  in  intestine  of,  49. 

Infant  le  diarrhoea,  treatment  of,  146. 

Ingluvin,  108. 

Inflammation,  202,  219. 

heat  of  blood  in,  207. 

minute  particles  of  bioplasm  passing 

through  vessels,  247. 

slight,  248. 

Inhalers,  68. 

Injection,  123. 

hypodermic,  192. 

Iniury  in  case  of  a  flea-bite,  226. 

hv.jrcostal  muscles,  pain  in,  194. 

Intermolecular  circulation,  39. 

In'estinal  canal,  ganglia  and  nerves  of,  228. 

nerves  of.  86. 

inflammation  of,  265. 

worms,  152. 

Iodide  of  potassium  in  cracks  of  tongue, 
66. 

in  rheumatism,  199. 

Iodine  in  chilblains,  269. 

Ipecacuanha  as  an  emetic,  92. 

in  ulcers  of  colon,  267. 

Iron,  its  influence  in  darkening  the  mo- 
tions, 150. 

tincture  of,  in  sore  throat,  262. 

muriated  tincture  of,  in  thrush,  71. 

in  neuralgia,  191. 

Irritability  in  biliousness,  158. 

of  dyspeptic  persons,  94. 

Irritation  of  mucous  membrane,  253. 

—  ofstamach  causing  diarrhoea,  145. 
Issue,  254 

Itching  in  chilblains,  269. 

JALAP  in  constipation,  136. 
I       Jaundice,  163. 

Joints,  state  of,  in  rheumatism,  195. 
Juglandin,  163. 


T7"  ETTLE,  bronchitis,  68. 
lV     Kino,  151. 
Kneading  the  bowels,  127. 
Krameria,  151. 

LARGE    intestine    deranged    in    sick 
headache,  171. 
Lavement,  123. 

Leaves,  fungi  of,  46.  ^  '. 

Lemon-juice  when  mouth  dry,  60. 
Lentils,  266. 
Leptothrix  buccalis,  45. 
Licorice  powder,  compound,  in  constipa- 
tion, 137. 

Lime-water  in  diarrhoea,  147. 
Liquid  taken,  its  influence  on  action  of 

bowels,  117. 
Liquor  sanguinis,  241. 
bioplasm  in,  222. 


Lips,  vascularity  of,  255. 
Literary  men,  constipation  of,  1 1 5. 
Liver,  its  deranged  action  in  biliousness, 
1 60. 

exciting    action    of,     in     offensive 

breath,  73. 

in  sick  headache,  171. 

Living  matter,  changes  in,  247. 
particles,   passage   of,   through  ves- 
sels, 241. 
Local  injury,  vascular  disturbances   from, 

237- 

Logwood,  151. 
Loss  of  appetite,  76. 
Lotion  for  eyes,  260. 
Lozenges,  bismuth,  in  dyspepsia,  96. 
Lumbago,  194. 
Lungs,   capillary  haemorrhage   from   the, 

241. 

ll/f  ANAGEMENT  of  patients,  21. 
1V1      Manson,  Dr.,  on  filaria,  238. 
Mastication,  defects  of,  IOO. 
Materies  morbi,  54. 

Meat  in  inflamed  mucous  membrane  of 
stomach,  266. 

little  required  by  bilious  people,  l6f. 

too  much,  98. 

Mechanism  for  governing  calibre  of  ar- 
teries, 232. 

for  regulating  capillary  circulation, 

232. 

Me'niere's  disease,  157. 

Mercury  in  sick  headache,  175. 

its  use  in  offensive  breath,  74. 

Metallic  taste  in  mouth,  70. 

Micrococci,  45. 

Microscopic  ganglia,  70. 

observation,  38. 

Mildew,  vital  phenomena  of,  246. 
Milk  and  lime-water,  147. 
Mind  in  sick  headache,  170. 
Mindererus,  215. 

Misery  and  despair  in  biliousness,  159. 
Moist  application  to  bowels  in  constipation, 
126. 


INDEX. 


28l 


Molecular  circulation,  39. 

Morphia,  its  influence  on  t"he  circulation, 

238. 
Mortification,  223. 

following  boils,  270. 

Movements  of  mucus-corpuscles,  250. 

vital,  223. 

Mouth,  aphthae  in,  70. 

— —  dryness  of,  58. 

Muco  pus,  264. 

Mucous  membrane,  inflamed,  249,  264. 

of  stomach,  inflamed,  265. 

Mucus  corpuscle,  250. 

evacuations,  148. 

formation  of,  250. 

of  pig's  stomach  as  pepsine,  105. 

secreted  in  a  cold,  253. 

Muscular  fibre  cells  of  intestine,  86. 

of  small  artery,  227,  235. 

rheumatism,  195. 

Mustard  as  an  emetic,  92. 

leaf,  mode  of  using,  266. 

Myrrh,  tincture  of,  in  cases  of   offensive 

breath,  73. 

N'ARES,  dryness  of,  67. 
Natural  history  of  disease,  37. 
Nausea,  79. 

in  sick  headache,  168. 

Nerve,  action  of,  determining  calibre  of 

arteries,  227. 
cells  and  fibres  governing  capillary 

circulation,  228. 

circuit,  236. 

•  derangement  in  sick  headache-,  173. 

disorders,  relation  of  fever  to,  220. 

disturbance  in  chill >lains,  269. 

fibres  concerned  in  pain,  251. 

eruptions  in  course  of,  252. 

of  stomach  and  intestine,  85. 

—  storms,  174. 

Nerves  of  digestive  system,  55. 

to  capillary  vessels,  230. 

and  ganglia,  stomach,  85. 

of  hyla,  228. 

of  intestinal  canal,  86. 

Nervous  excitement  producing  diarrhoea, 

144. 

Nervousness,  187. 
Neuralgia,  189. 

treatment  of,  190. 

Neuralgia  and  gouty  affections,  and   sick 

headache,  174. 
Nitrate  of  silver  in  sore  throat,  68. 

—  in  treating  sores  on  lips,  256. 
Nose,  haemorrhage  from,  243. 
Nucleus  of  a  ceil,  250. 
Nutritive  matters,  113. 

Nux  vomica  in  constipation,  137. 

OATMEAL  in  constipation,  113,  127. 
Odor  of  the  breath,  72. 
Offensive  breath,  72. 
Oidium  albicans,  45. 

24* 


Old  age;  accumulation  of  fsecal  matter  in, 
116. 

indigestion  in,  100. 

Olive  oil,  146. 

Oozing  of  blood  from  capillaries,  241. 

Operation,  fever  after,  treatment  of,  1 19. 

Ophthalmia,  .257. 

— —  poison  of,  273. 

Opium  in  diarrhoea,  152. 

homoeopathic  doses,  28. 

Ostrich -pepsine,  107. 

Outgrowths  from  bioplasm,  247. 

Out-patient  department  of  hospitals,  35. 

Over-sensitiveness  in  sick  headache,  173. 

Oxidation  not  increased  .in  fever  and  in- 
flammation, 207,  222. 

DAIN,  85, 

1        conducting  nerve-fibres,  88. 

nerve-fibre  concerned  in,  ii;i. 

neuralgic.  190. 

pleuritic,  252. 

in  the  stomach,  266. 

rheumatic,  193,  197. 

Palate,  soft,  dryness  of,  67. 

Papillae   of   tongue,    filiform,    and    fungi 

form.  43. 
Paralyzing    action    of   nerve-centres    and 

fibres,  236. 

Pathological  changes,  nature  of,  52. 
Peculiarity  of  dress,  28. 
Pepsine,  and  its  uses,  102. 

of  the  pig,  105. 

of  the  ostrich,  107. 

Peptones,  no. 

Pericarditis,  pain  in,  88. 

Periodical  sick  headaches,  173. 

Peripheral  paralysis,  261. 

Peritonitis,  88. 

Perspiration,  free,  in  rheumatism,  197. 

Peruvian  balsam,  270. 

Petechise,  224. 

Pharynx,  changes  in  mucous    membrane. 

of,  68. 

Phosphate  of  soda,  142. 
Physical  views  of  vital  aciion,  246. 
Phytolaccin,  163. 
Pig,  pepsine  of,  105. 
Piles  or  hcemorrhoids,  120. 
Pleurisy,  pain  in,  89,  251. 
Plexuses,  nerve,  87. 
Pneumonia,  274. 

increased  oxidation  in,  208. 

PodophylHn  in  constipation,  139. 

Poison  of  disease,  274. 

Pork,  its  dethronement  in  America,  189. 

Port  wine  as  a  gargle,  263. 

Poultice,  its  use  in  treatment  of  ulcer  of 

stomach,  266. 

in  dyspepsia,  97. 


Preliminary    changes    in    febrile    attacks, 

204. 

— : —  various  diseases,  273. 
Pressure  in  causing  chilblains,  268. 


282 


INDEX. 


Principles    of   treatment    of    slight    and 

severe  ailments,  35. 
Prescribing,  36. 
Prunes  in  constipation,  128 
Prussic  acid  in  nausea,  83. 
Pullna  water,  142. 
Purgative  enemata,  123. 
Purgatives  in  cases  of  offensive  breath,  74. 

in  a  cold,  21=;. 

in  constipation,  131. 

in  indigestion,  93. 

Pus  from  bioplasm  of  epithelium,  223. 

corpuscles,  formation  of,  223. 

in  boils,  271. 

not  altered<  blood-corpuscles,  240. 

formation  of,  in  and  near  capillaries, 

239- 

Putrid  fluids,  bacteria  in,  47. 
Pyrethrum,  60. 
Pyrosis,  90. 

QUACKERY,  27. 
its  consequences,  32. 

Quinine,  action  of,  40. 

RASH  in  fever,  220. 
Reabsorption   of  fluids   from   intes- 
tine, 117. 

Rectum,  bleeding  from  the,  243. 
Redness  of  skin  in  fever,  220. 

in  flea  bite,  224. 

Regularity  of  action,  importance  of,  96. 
Reputation  of  quacks,  33. 
Rest,  importance  of.  57. 

in  sick  headache,  177. 

importance  of,  in  treatment,  266. 

Restlessness,  185. 
Rhatamy,  tincture  of,  152. 
Rheumatic  pains,  193. 
Rheumatism,  tongue  in,  61. 

causes  of,  274. 

treatment  of.  196. 

Rhubarb  in  constipation,  132,  135. 

Rigors,  210. 

Rubbing  in  constipation,  126. 

in  liniments,  267. 

Running  from  the  ear,  264. 
Rocheile  salts,  142. 

SALTCINE,  191. 
Saline    purgatives    in    constipation, 
140. 

Salines,  action  of,  57. 
Saliva,  exciting  flow  of,  60. 
Salt  as  a  gargle,  263. 
Santonin,  154. 
Sarcina  ventriculi,  45. 
Scammony  in  constipation,  137. 
Scarlet  fever,  rash  in,  220. 
Scepticism,  31. 

Scrofulous  children,  ophthalmia  in,  257. 
Sea-side  causing  biliousness,  163. 
Secretion,  free,  213. 

importance  of,  in  preventing  illness, 

273- 


Self-supporting  dispensaries,  35. 

Senses  disturbed  in  sick  headache,  173. 

Sensitiveness  of  inflamed  mucous  mem- 
brane,  251. 

of  peritoneum,  88. 

Serious  diseases,  36. 

Serous  membranes,  pain  in,  when  in- 
flamed, 88. 

Shampooing  in  rheumatism,  197. 

Shrinking  of  muscles  in  rheumatism,  195. 

Shivering  and  rigors,  203. 

Sialogues,  60. 

Sick  headache,  167. 

treatment  of,  175- 

Slight  inflammation,  248. 

Smoking    as   a   remedy   for   constipation, 

I3I- 

Sordes,  64. 
Sore  on  lips,  254. 

on  mouth,  70. 

throat,  260. 

state  of  mucous  membrane  in,  252. 

Spirit  of  Mindererus,  215. 
Spray  in  treating  sore  throat,  68. 
Starving  in  sick  headache,  177. 
Steel,  tincture  of,  71. 
Stings  or  bites  of  gnats,  237. 
Stimulants  in  sick  headache,  173,  176. 
Stomach,  derangement  of,  in  sick  head- 
ache, I/O. 

poulticing  the,  266. 

acids  of,  91. 

capillary  haemorrhage  from  the,  244. 

fungi  in,  48. 

irritation  of,  producing  fever,  146. 

of  pig,  105. 

ulcer  of,  265. 

wind  in  the,  92. 

Sudden  illness,  274. 
Sulphate  of  magnesia  and  soda,  141. 
.Sulphurous  acid  gargle,  65. 
Swallowing,  260. 
Sweating  in  rheumatism,  200. 
— -  stage  in  fever,  210. 
Sycophants,  27. 

Sympathetic  system,  nerves  of,  86. 
Syringes  for  injections,  124. 

'"PACT  and  treatment,  25. 
1       Tannic    acid,  glycerine    of,  in    sore 

throat,  68. 

Tannin,  use  in  sore  throat,  262. 
Tapeworm,  154. 
Tarlar  emetic,  80. 
Tartrate  of  soda  and  potash,  142. 
Taste,  metallic,  in  the  mouth,  70.  , 

Tasteless  salt,  141. 
Tea-drinking  in  sick  headache,  179. 
Teetotalism,  82. 

Teeth,  loss  of,  causing  dyspepsia,  100. 
Temperature  of  body,  ascertaining,  209. 

—  rise  of,  in  febrile  states,  206. 
Temporary  jaundice,  164. 
Tendons  in  rheumatism,  195. 
Thermometer,  use  of,  209. 


INDEX. 


283 


Thickening  and  condensation  of  connect- 
ive tissue,  247. 
Thirst,  83. 

Thought  in  sick  headache,  170. 
Threadworms,  153. 
Thrush,  70. 

Tissues,  changes  of,  in  inflammation,  219. 
Tobacco,  a  cause  of  vertigo.  156. 
Tobacco-smoking  in  constipation,  131. 
Tongue,  42. 

cracks  and  fissures  of,  65. 

dry  and  moist,  58. 

in  various  derangements,  55. 

in  vegetable  organisms  on,  45. 

Tonics,  in  chilblains,  269. 

Toothache,  190. 

Trades,  constipation  dependent  on  various, 

114. 

Transudation  of  fluid  through  vessels,  145. 
Treatment  of  aphthaj,  71. 

of  boils,  271. 

of  chilblains,  269. 

of  a  cold,  214. 

of  drowsiness,  185. 

empirical,  267. 

of  inflamed  mucous  membrane,  255. 

of  rheumatism,  196. 

of  sick  headache,  175. 

• •  of  slight  ailments,  principles  of,  36. 

of  sore  throat,  261. 

Turkish  bath  in  rheumatism,  197. 
Turpentine  in  chilblains,  270. 


u 


LCER  of  bowel,  267. 

of  stomach,  265. 

-  in  mouth,  70. 

of  mucous  membrane,  249. 


Urea,  excess  of,  in  fever,  208. 
Urine  in  sick  headache,  173. 


VALLISNERIA,  bioplasm  of  cells  of 
245. 

cells  of  leaf  of,  47. 

Vapor-bath  in  rheumatism,  197. 
Vascular  disturbance  resulting  from  local 

injury,  237. 

Veins,  state  of,  in  haemorrhoids,  121. 
Vertigo,  154. 

Vessels  in  fever  and  inflammation,  2T2O. 
Villi,  nerves  of,  87. 
Virulent  pus-corpuscles,  257. 
Vital  movements,  250. 
Vomiting,  80. 

—  in  sick  headache,  168,  180. 
Voracious  appetite,  77. 
Vulgarity  of  manner,  28. 

TT7AKEFULNESS,  185. 
VV       Warm-blooded  animals,  206, 
Warm  clothing,  importance  of,  99,  2O2. 
WTarmth,  importance  of,  149,  151,202. 

chilblains  treated  by,  268. 

in  sick  headache,  178. 

—  in  treating  pain  in  the  stomach,  266. 
Wasting  of  muscles  in  rheumatism,  195. 
Water  in  treating  biliousness,  162. 
Waterbrash,  90. 

Weakness  as  a  consequence  of  dyspepsia, 

102. 

White  moist  furred  tongue,  61. 
Wind  in  the  stomach,  92. 
Woollen  clothing,  importance  of,  99. 
Worms,  intestinal,  152. 
Wounds  do  not  heal  i.n  constipation,  119. 
not  healing  in  sick  headache,  170. 

T7"  AWNING  in  sick  headache,  169. 
JL       Yeast  in  treating  boils,  272. 
Yellow  atrophy  of  liver,  166. 


THE  END. 


MARCH,  1887. 
CATALOGUE 

^         CATALOGUE 


MEDICAL,  DENTAL, 

Pharmaceutical  &  Scientific  Publications, 

WITH  A  CLASSIFIED  INDEX, 

PUBLISHED    BY 

P.   BLAKISTON,    SON   &   CO., 

(SUCCESSORS  TO  LINDSAY  &  BLAKISTON) 

Booksellers,  Publishers  and  Importers  of  Medical  and  Scientific  Books, 
'      No.  1012  WALNUT  STREET,  PHILADELPHIA. 


THE  FOLLOWING  CATALOGUES  WILL   BE   SENT  FREE  TO  ANY  ADDRESS, 
UPON  APPLICATION. 

This  Catalogue,  including  all  of  our  own  publications. 

A  Catalogue  of  Books  for  Dental  Students  and  Practitioners. 

A  Catalogue  of  Books  on  Chemistry,  Pharmacy,  The  Microscope,  Hygiene,  Human  Health, 
Sanitary  Science,  Technological  Works,  etc. 

Students'  Catalogue,  including  the  "Quiz-Compends"  and  some  of  the  most  prominent  Text- 
books and  manuals  for  medical  students. 

A  Complete  Classified  Catalogue  (48  pages)  of  all  Books  on  Medicine,  Dentistry,  Pharmacy 
and  Collateral  Branches.     English  and  American. 

A  Catalogue  of  Medical  and  Scientific  Periodicals  and  Physicians'  Visiting  Lists,  giving  club  rates. 
P.  Blakiston,  Son  &  Co.'s  publications  may  be  had  through  Booksellers  in  all  the  principal 

cities  of  the  United  States  and  Canada,  or  any  book  will  be  sent,  postpaid,  by  the  publishers, 

upon  receipt  of  price,  or  will  be  forwarded  by  express,  C.  O.  D.,  upon  receiving  a  remittance  of 

25  per  cent,  of  the  amount  ordered,  to  cover  express  charges.     Money  should  be  remitted  by 

postal  note,  money  order,  registered  letter,  or  bank  draft. 
i  B®""  All  new  books  received  as  soon  as  published.     Special  facilities  for  importing  book» 

from  England,  Germany  and  France 


CLASSIFIED  LIST,  WITH   PRICES, 

OF  ALL  BOOKS  PUBLISHED  BY 
P.  BLAKISTON,  SON  &  CO.,  PHILADELPHIA. 

or  further  information  in  reference  to  these  Books,  see  following  descriptive  catalogue,  which  will  be  sent, 
free,  to  any  address.    When  the  price  is  not  given  below,  the  book  is  out  of  print  or  about  to  be  published. 
Cloth  binding,  unless  otherwise  specified. 


ANESTHETICS. 

Sansom.     Chloroform.    - 
Turnbull.     2d  Ed. 
Cocaine. 

ANATOMY. 

Handy.  Text-book. 
Heath.  Practical.  - 
Holden.  Dissector. 

Landmarks.  - 

Potter.     Compend   of.     New 

Ed.     208  Illustrations.  - 
Wilson.     loth  Ed. 

ATLASES  AND  DIAGRAMS 

Bentley  and  Trimens. 

Medicinal  Plants.  - 
Braune.     OfAnatomy.    - 
Flower.     Of  Nerves. 
Godlee.     Of  Anatomy.    - 
Heath.     Operative  Surgery.    12.00 
Hutchinson.     Surgery.  -        25.00 
Jones.     Membrana  Tympani.   4.00 
Marshall's  Physiol.  Plates.    80.00 
Schultze.  Obstetrical  Plates.  25.00 

BRAIN  AND  INSANITY. 

Bucknill  and  Tuke.  Psychologi- 
cal Medicine. 

Gowers.  Diagnosis  of  Diseases  of 
the  Brain. 

Mann's  Psychological  Med.     5.00 

Roberts,  Surgery  of 

Wood.     Brain  and  Overwork      .50 

CHEMISTRY. 

Allen.    Commercial  Analysis. 

ume  I.     -         - 
Bartley.     Medical. 
Bloxam's  Text-Book. 

Laboratory. 

Bowman's  Practical. 
Frankland.     How  to  Teach. 
Leffmann's  Compend.     - 
Muter.     Med'l  and  Pharm. 
Richter's  Inorganic. 

Organic. 

Stammer.     Problems.     - 
Sutton.     Volumetric  Anal. 
Thompson's  Physics.     - 
Trimble.     Analytical. 
Vacher's  Primer  of. 
Valentin.     Qualt.  Analy. 
Ward's  Compend  of. 
Watts.     (Fowne's)  Inorg. 

(Fowne's)  Organ. 

Wolff.  Applied  Medical  Chem 

istry.        -        -        -        -          1.50 

CHILDREN. 

Chavasse.  Mental  Culture  of.  i.oo 
Day.  Diseases  of.  -  -  3.00 
Dillnberger.  Women  and.  1.50 
Ellis.  Mother's  book  on.  .75 

Goodhart  and  Starr.  3.00;  8)1.3.50 
Hale.  Care  of.  -  -  .75 

Hillier.     Diseases  of.       -  1.25 

Meigs.      Infant   Feeding    and 

Milk  Anilysis.  -  -  i.oo 
Meigs  and  Pepper's  Treatise. 5.00 
Smith.  Wasting  Diseases  of.  3.00 
Starr,  Digestive  Organs  of,  2.50 


COMPENDS 

$1.25 

And  The  Quiz-Contpends. 

1.50 

Brubaker's  Physiol.    3d  Ed.  $1.00 

•5° 

Fox  and  Gould.     The  Eye.    i.oo 

Horwitz.     Surgery.     2d  Ed.   i.oo 

Hughes.  Practice.  2  Pts.  Ea.  i.oo 

Landis.    Obstetrics.     2d  Ed.  i.oo 

3-oo 

Leffmann's  Chemistry.             i.oo 

5-00 

Mendenhall's  Vade  Mecum.  

4-5° 

Potter's    Anatomy,   including 

- 

Visceral  Anatomy.   100  IIlus.  i.oo 

r 

I.OO 

Roberts.  Mat.  Med.  and  Phar.  2.00 

6.00 

Stewart,  Pharmacy.        -          i.oo 

Ward's  Chemistry.    2d  Ed.     i.oo 

VIS. 

DEFORMITIES. 

Churchill.     Face  and  Foot.      3.50 

75.00 

Coles.     Of  Mouth.           -          4.50 

8.00 

Prince.     Orthopaedics.     -          4.50 

3-5° 

Reeves.            "                 -          2.25 

20.00 

12.00   |                    DENTISTRY. 

25.00 

Barrett.     Dental  Surg.   -          i.oo 

4.00 

Flagg.     Plastics.     -        -          4.00 

io.oo      Gorgas.     Dental  Medicine.      3.25 

25.00 

Harris.     Principles  and  Prac.  6.50 

f.           Heath.     Dis.  of  Jaws.    -          4.50 

Hunter.     Mechanical  Dent.      1.50 

logi- 

Leber    and    Rottenstein. 

8.00 

Caries.     -                                        1.25 

es  of 

Richardson.     Mech.  Dent.      4.50 

Stocken.     Materia  Medica.      2.50 

5.00 
1.25 

Taft.    Operative  Dentistry.       4.25 

•  5° 

Tomes.     Dental  Surgery.         

'White.    Mouth  and  Teeth.         .50 

Vol- 

DICTIONARIES. 

4.50 

Cleveland's  Pocket  Medical.     .75 

2.50 

Cooper's  Surgical.   -        -         12.00 

3-75 

Harris'  Dental.        -        -          6.50 

'•7S 

Longley's  Pronouncing  -          i.oo 

2.OO 

_^_ 

DIRECTORY. 

I.OO 

Medical,  of  Philadelphia, 

6.00 

Pa.,  Del.  and  South  N.  J.       2.50 

2.0O 

EAR. 

3.00 

Burnett.     Hearing,  etc.              .50 

•75 

Dalby.     Diseases  of.        -          1.50 

5-oo 

Jones.    Aural  Surgery.     -          2.75 



Pritchard.     Diseases  of.            1.50 

1.50 
.50 

Woakes.     Deafness,  etc.           1.50 

3.00 

I.OO 

ELECTRICITY. 

2.25 

Althaus.  Medical  Electricity.  6.00 

2.25 

Mason's  Compend.           -          i.oo 

L- 

Reynolds.    Clinical  Uses.         i.oo 

EYE. 

Arlt.  Diseases  of.  -  -  2.50 
Carter.  Eyesight.  -  -  1.25 
Daguenet.  Ophthalmoscopy.  1.50 
Fox  and  Gould.  Compend.  i.oo 
Gowers.  Ophthalmoscopy.  6.00 
Harlan.  Eyesight.  -  .50 

Hartridge.     Refraction.  2.00 

Higgins.     Handbook.      -  .50 

Liebreich.    Atlas  of  Ophth.    15.00 
Macnamara.     Diseases  of.       4.00 
Meyer  and    Fergus.       Com- 
plete Text-Book,  with   Colored 

Plates.     

Morton.     Refraction.  3d  Ed.    i.oo 


FEVERS. 

Collie,  On  Fevers.  -        -  $2.50 

Welch.     Enteric  Fever.    -  2.00 

HEADACHES. 

Day.     Their  Treatment,  etc.  1.25 

Wright.     Causes  and  Cure.  .50 

HEALTH  AND  DOMESTIC 

MEDICINE. 

Bulkley.    The  Skin.        -  .50 

Burnett.     Hearing.         -  .50 

Cohen.     Throat  and  Voice.  .50 

Dulles.     Emergencies.    -  .75 

Harlan.     Eyesight.         -  .50 

Hartshorne.     Our  Homes.  .50 

Hufeland.     Long  Life.   -  i.oo 

Lincoln.     Hygiene.         -  .50 

Osgood.     Winter.    -        -  .50 

Packard.    Sea  Air,  etc.  .50 

Richardson's  Long  Life.  .50 

Tanner.     On  Poisons.     -  .75 

White.     Mouth  and  Teeth.  .50 

Wilson.  Summer.  -  .50 
Wilson's  Domestic  Hygiene,  i.oo 

'Wood.     Brain  Work.      -  .50 

HEALTH  RESORTS. 
Madden.     Foreign.          -          2.50 
Packard.   Sea  Air  and  Bath'g.   .50 
Solly.     Colorado  Springs.  .75 

HEART. 

Balfour.     Diseases  of.     -  5.00 

Fothergill.     Diseases  of.  3.50 

Sansom.     Diseases  of.     -  1.25 

HISTOLOGY. 
See  Microscope  and  Pathology. 

HOSPITALS. 
Burdett.     Cottage  Hospitals.  4.50 

Pay  Hospitals.      -          2.25 

Domville.     Hospital  Nursing.    .75 

HYGIENE. 

Bible  Hygiene.  -  -  i.oo 
Frankland.  Water  Analysis,  i.oo 
Fox.  Water,  Air,  Food.  4.00 
Lincoln.  School  Hygiene.  .50 
Parke's  Hygiene.  6th  Ed.  3.00 
Wilson's  Handbook  of.  -  2.75 
Domestic.  -  -  i.oo 

Drainage.     -        -  i.oo 

Naval.           -        -  3.00 

KIDNEY  DISEASES. 
Beale.     Renal  and  Urin.  1.75 

Edwards.     How  to  Live  with 

Bright's  Disease.    -        -  .50 

Greenhow.  Addison's  Dis.  3.00 
Ralfe.  Dis.  of  Kidney,  etc.  2.75 
Tyson.  Bright's  Disease.  3.50 

LIVER. 

Habershon.  Diseases  of.  1.50 
Harley.  Diseases  of.  -  3.00 

LUNGS  AND  CHEST. 
See  Phy.  Diagnosis  and  Throat. 

MARRIAGE. 
Ryan.     Philosophy  of.     -          i.oo 

MATERIA  MEDICA. 

Biddle.     loth  Ed.    -        -  4.00 

Charteris.     Manual  of.  -         

Gorgas.     Dental.     -        -  3.00 

Merrell's  Digest.             -  4.00 

Phillips.     Vegetable.       -  7.50 

Potter's  Compend  of.      -  i.oo 

Handbook  of.          -  3.00 

Roberts'  Compend  of.     -  2.00 


CLASSIFIED  LIST  OF  P.  BLAK1STON,  SON  &•  CO.'S  PUBLICA  TIONS. 


MEDICAL  JURISPRUDENCE. 
Abercrombie's  Handbook,    $2.50 
Reese's  Text-book  of.  3.00;  Sh.  3.50 
Woodman  and  Tidy's  Treat- 
ise, including  Toxicology.       7.50 

MICROSCOPE. 
Beale.     How  to  Work  with.     7.50 

In  Medicine.         -          7.50 

Carpenter.     The  Microscope.  5.50 
Lee.     Vade  Mecum  of.    -          3.00 
MacDonald.     Examination  of 

Water  by.  ...  2.75 
Martin.  Mounting.  -  2.75 
Wythe.  The  Microscopist.  3.00 

MISCELLANEOUS. 
Allen.     The  Soft  Palate.  .50 

Beale.     Life  Theories,  etc.        a.oo 

Slight  Ailments.  1.25 

Our  Morality.      -          i.oo 

Black.     Micro-Organisms.         1.50 
Cobbold.     Parasites,  etc.  5.00 

Edwards.     Malaria.        -  .50 

— — —     Vaccination.         -  .50 

Gross.     Life  of  Hunter.  1.25 

Hare.    Tobacco.  Paper,  .50 

Hodge.     Fosticide.  -  .50 

Holden.   The  Sphygmograph.  2.00 
Kane.     Opium  Habit.      -          1.25 
MacMunn.  The  Spectroscope  3.00 
Murrell.     Massage,  ad  Ed.       1.25 
Smythe.     Med'l  Heresies.        1.25 
Wickes.  Sepulture.         -          1.50 

NERVOUS  DISEASES. 
Buzzard.     Ner.  Affections.       5.00 
Flower.   Atlas  of  Nerves.         3.50 
Gowers.    Dis.  of  Spinal  Cord. 

Epilepsy.      •  4.00 

•  Manual  of.     Vol.  I     -      4.50 

Page.     Injuries  of  Spine.  3.50 

Radcliffe.  Epilepsy,  Pain,  etc.  1.25 
Wilks.     Nervous  Diseases,      6.00 

NURSING. 

Brush,  Nursing  of  the  Insane.  

CuUingworth.    Manual  of.  i.oo 

Monthly   Nursing.  .50 

Domville's  Manual.        -  .75 

Hood.     Lectures  to  Nurses.  i.oo 

Liickes.     Hospital  Sisters.  i.oo 

Record  for  the  Sick  Room.  .25 

Temperature  Charts.    -  .50 

OBSTETRICS. 

Barnes.  Obstetric  Operations.  3.75 
Cazeaux  and  Tarnier.    New 

Ed.  Colored  Plates.  -  n.oo 
Galabin's  Manual  of.  -  3.00 
Glisan's  Text-book.  -  4.00 
Landis.  Compend.  -  i.oo 
Meadows.  Manual.  -  2.00 
Rigby  and  Meadow's.  -  .50 

Schultze.     Diagrams.     -        25.00 
Swayne's  Aphorisms      -          1.25 

OSTEOLOGY. 
Holden's  Text-book.      -          

PATHOLOGY  &  HISTOLOGY. 

Gibbes.    Practical    -        -  1.75   i 

Gilliam.     Essentials  of.  -  2.00 

Paget's  Surgical  Path.     -  7.00  | 

Rindfleisch.     General.  2.00 

Sutton.     General  Path.  -  4.50   • 

Virchow.     Post-mortems.  i.oo 

Wilkes  and  Moxon.    -  6.00 

PHARMACY. 
Beasley's  Druggists'  Rec'ts.    2.25   ; 

Formulary.      -        -          2.25 

Fliickiger.     Cinchona  Barks.  1.50   ' 
Kirby.     Pharm.  of  Remedies.  2.25   j 
Mackenzie.  Phar.  of  Throat.  1.25 
Merrell's  Digest.     -        -          4.00  i 
Piesse.     Perfumery.        -          5.50 


2.25 
i.oo 


1.50 

4.00 

•75 

12. OO 
1.25 
1.25 


Proctor.     Practical  Pharm.  $4.50 

Roberts.     Compend  of.  2.09 

Stewart's  Compend.       -  i.oo 

Tuson.     .Veterinary  Pharm.  2.50 

PHYSICAL  DIAGNOSIS. 
Bruen's  Handbook.     2d  Ed.    1.50 

PHYSIOLOGY. 
Beale's  Bioplasm.    - 
Brubaker's  Compend.     - 
Kirkes'  nth  Edition. 

Cloth,  4.00;  Sheep,  5.00 
Landois'  Text-book.  2d  Ed.  6.50 
Sanderson's  Laboratory  B'k.  5.00 
Tyson's  Cell  Doctrine.  -  2.00 
Yeo's  Manual  2d  Ed.  Cl,  3.00; 
Sheep,  3.50 

POISONS. 

Black.     Formation  of.     - 
Reese.    Toxicology. 
Tanner.     Memoranda  of. 

PRACTICE. 

Aitken.    2  Vols.     New  Ed. 
Beale.     Slight  Ailments. 

Charteris.     Handbook  of.         , 

Fagge's  Practice.  2  Vols.  10.00 
Fenwick's  Outlines  of.  -  1.25 
Hughes.  Compend  of.  2  Pts.  2.00 
Roberts.  Text-book,  sth  Ed.  5.00 
Tanner's  Index  of  Diseases.  3.00 
Warner's  Case  Taking.  1.75 

PRESCRIPTION  BOOKS. 
Beasley's  3000  Prescriptions.   2.25 
Receipt  Book.        -          2.25 

Formulary.     -        -          2.25 

Pereira's  Pocket-book.  i.oo 

Wythe's  Dose  and  Symptom 

Book.      -        -        -        -          i.oo 

RECTUM  AND  ANUS. 
Allingham.    Diseases  of.          1.25 
Cripps.   Diseases  of.        -          4.50 

SKIN  AND  HAIR. 
Anderson's  Text-Book,  4.50 

Bulkley.    The  Skin.         -  .50 

Cobbold.  Parasites.  -  5.00 
Van  Harlingen.  Diagnosis 

and  Treatment  of  Skin  Dis.   1.75 
Wilson.     Skin  and  Hair.          i.oo 

STIMULANTS  &  NARCOTICS. 
Anstie.  On.  -  -  3.00 

Hare,  Tobacco.  Paper,  .50 

Kane.  Opium  Habit,  etc.  1.25 
Lizars.  On  Tobacco.  -  .50 

Miller.     On  Alcohol        -  .50 

Parrish.     Inebriety.        -          1.25 

STOMACH  &  INDIGESTION. 
Gill.  Indigestion.  -  -  1.25 

SURGERY. 

Gamgee.    Wounds  and  Frac- 
tures.      -        ...          3.50 
Heath's  Operative.          -        12.00 

Minor.    Sth  Ed.      -          2.00 

— —  Surgical  Diagnosis.  1.25 

Diseases  of  Jaws.  4.50 

Horwitz.   Compend.   2d  Ed.    i.oo 
Hutchinson's  Clinical    -        25.00 
Mears.     Practical.  -          3.00 

Porter's    Surgeon's    Pocket- 
book.       -  2.25   j 

Pye.     Surgical  Handicraft.        5.00   i 
Roberts.     Surgical  Delusions.    .50  i 

(A.  S.)   Club-Foot.  .50 

Watson's  Amputations.  5.50 

TECHNOLOGICAL  BOOKS. 

See  also  Chemistry. 
Cameron.     Oils  &  Varnishes.  2.50  j 
Gardner.     Brewing,  etc.  1.75 

Bleaching  &  Dyeing.     1.75 

Gardner.    Acetic  Acid,  etc.      1.75  i 


Overman.     Mineralogy.  Ji.oo 

Piesse.     Perfumery,  etc.  5.50 

Piggott.     On  Copper.      -  i.oo 

Thompson.     Physics.     -  - 

THERAPEUTICS. 
Biddle.  loth  Ed.  -  -  4.00 
Cohen.  Inhalations.  -  1.25 
Field.  Cathartics  and  Emetics.  - 
Headland.  Action  of  Med.  3.00 
Kirby.  Selected  Remedies.  2.25 
Mays.  Therap.  Forces.  1.25 

Ott.  Action  of  Medicines.  2.00 
Phillips.  Vegetable.  -  7.50 
Potter's  Compend.  -  i.oo 

-  ,  Handbook  of.  3.00  ;  Sh.  3.50 
Waring's  Practical.        -          3.00 

THROAT  AND  VOICE. 
Cohen.     Throat  and  Voice. 

-  Inhalations. 
Greenhow.     Bronchitis. 
Holmes.     Laryngoscope. 
James.     Sore  Throat 
Journal  of  Laryngology. 
Mackenzie.   Nose,  etc. 

-  Larynx. 

-  Hay  Fever. 
--     Pharmacopoeia.    - 
Potter.     Defects  of  Speech. 

TRANSACTIONS  AND 

REPORTS. 

Penna.  Hospital  Reports.  1.25 
Power  and  Holmes'  Reports.  1.25 
Trans.  College  of  Physicians.  3.50 

-  Amer.  Surg.  Assoc.        4.00 

TUMORS  AND  CANCER. 
Hodge.    Note-book  for.  .50 

Thompson.  Of  the  Bladder.  1.75 
Wells.  Abdominal.  -  1.50 

URINE  &  URINARY  ORGANS. 
Acton.  Repro.  Organs.  2.00 

Beale.     Urin.  &  Renal  Dis.      1.75 

-  Urin.  Deposits.    Plates.  2.00 
Curling.     On  the  Testes.          5.50 
Legg.     On  Urine.     -  .75 
Marshall  and  Smith.  Urine,  i.oo 
Thompson.  Urinary  Organs.  1.25 

-  Surg.  of  Urin.  Organs.    1.25 


•So 
1.25 
1.25 
i.oo 
1-25 
3.00 
3.00 
1-25 

•  50 
1-25 

I.OO 


Calculous  Dis. 
Lithotomy.     -        - 
Prostate.     6th  Ed. 
Tumors  of  Bladder. 
Stricture. 


i.oo 
3.50 
2.00 
1.75 
2.00 
1.50 


. 
Tyson.     Exam,  of  Urine. 

VENEREAL  DISEASES. 
Cooper.     Syphilis.  -        -          3.50 
Durkee.     Gonorrhoea.     -          3.50 
Hill  and  Cooper's  Manual,    i.oo 
Lewin.     Syphilis.  -        -          1.25 

VETERINARY  PRACTICE. 
Armatage's  Pocket-book  of.     1.25 
Tuson's  Vet.  Pharmacopoeia.  2.50 

VISITING  LISTS  AND  AC- 

COUNT BOOKS. 
Lindsay    and     Blakiston's 

Regular  Edition.  i.oo  to  3.00 

-  Perpetual  Edition.  1.25 

Watson's  Led.  and  Cash  Bk.  4.00 

WATER. 

Fox.     Water,  Air,  Food.  4.00 

Frankland.    Analysis  of.  i.oo 

MacDonald.        "         "  2.75 

WOMEN,  DISEASES  OF. 
Byford's  Text-book.        -          - 
--  Uterus.  ---          1.25 
Courty.  Uterus,  Ovaries,  etc.  7.50 
Dillnberger.    and  Children.    1.50 
Duncan.     Sterility.          -          2.00 
Galabin.     Diseases  of.     -          3.00 
Tilt.     Change  of  Life.      -          1.25 
Winckel,  by  Parvin.    Manual 
of.  Illus.  Clo.,3.oo;  Sh.  3.50 


PERIODICALS  PUBLISHED  BY  P.  BLAKISTON,  SON  &  CO. 

THE  POLYCLINIC. 

A  Monthly  Journal  of  Medicine  and  Surgery.  Doubled  in  Size  Without  Increase  of  Price. 

$1.00  PER  ANNUM.     SAMPLE  COPIES  FREE. 

EDITORIAL    STAFF. 
EDITOR-IN-CHIEF,  HENRY  LEFFMANN,  M.D. 

Diseases  of  the  Throat  and  Chest.  J.  SOLIS-COHEN,  M.D.,  Professor  of  Dis- 
eases of  the  Throat  and  Chest  in  the  Philadelphia  Polyclinic. 

General  Surgery,  or  Thopaedics,  Operative  and  Clinical  Surgery.  JOHN 
B.  ROBERTS,  M.D.,  Surg.  to  St.  Mary's  Hosp. ;  CHAS.  B.  NANCREDE,  M.D.,  Surg. 
to  the  Episcopal  and  to  St.  Christopher's  Hosps. ;  LEWIS  W.  STEINBACH,  M.D., 
WM.  BARTON  HOPKINS,  M.D.,  Asst.  Demonstrator  of  Surgery,  Univ.  of  Penna., 
A.  B.  HIRSH,  M.D. 

Diseases  of  the  Ear.  CHARLES  H.  BURNETT,  M.D.,  Aural  Surgeon  to  the  Presby- 
terian Hospital. 

Diseases  of  the  Mind  and  Nervous  System.  CHARLES  K.  MILLS,  M.D.,  Lec- 
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trations. 8vo.  Cloth,  $5.00 

COHEN  on  Inhalation,  its  Therapeutics  and  Practice,  including  a  Description  of 
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trations. A  New  Enlarged  Edition.  I2mo.  Paper,  .75;  Cloth,  $1.25 
The  Throat  and  Voice.  Illustrated.  i2mo.  Cloth,  .50 

COLES.  Deformities  of  the  Mouth,  Congenital  and  Acquired,  with  Their  Me- 
chanical Treatment.  By  OAKLEY  COLES,  M.D.,  D.D.S.  Third  Edition.  83  Wood 
Engravings  and  96  Drawings  on  Stone.  8vo.  Cloth,  $4.50 

COOPER  on  Syphilis  and  Pseudo-Syphilis.  By  ALFRED  COOPER,  F.R.C.S.,  Sur- 
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Octavo.  Cloth,  $3.50 


MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  9 

COURT  Y.  The  Uterus,  Ovaries,  etc.  A  Practical  Treatise  on  Diseases  of  the  Uterus, 
Ovaries  and  Fallopian  Tubes.  By  Prof.  A.  COURTY,  of  Montpellier,  France. 
Translated  from  the  Third  Edition,  by  his  pupil  and  assistant,  AGNES  MCLAREN, 
M.D.,  M.K.Q.C.P.I.  With  a  Preface  by  J.  MATHEWS  DUNCAN,  M.D.,  LL.D.,  F.R.S., 
Obstetric  Physician  to  Saint  Bartholomew's  Hospital,  London,  With  431  Illus- 
trations. 8vo.  Sold  by  Subscription.  Only  a  few  left  in  half  Russia,  $7.50 

COLLIE,  On  Fevers.  A  Practical  Treatise  on  Fevers,  Their  History,  Etiology, 
Diagnosis,  Prognosis  and  Treatment.  By  ALEXANDER  COLLIE,  M.D.,  M.R.C.P., 
Lond.  Medical  Officer  Homerton  Fever  Hospital,  and  of  the  London  Fever 
Hospital.  With  Colored  Plates.  Being  Volume 5,  Practical  Series.  Cloth,  $2  50 

CRIPPS.  Diseases  of  the  Rectum  and  Anus,  including  a  portion  of  the  Jackson- 
ian  Prize  Essay  on  Cancer.  By  HARRISON  CRIPPS,  M.D.,  Ass't  Surgeon  to  St. 
Bartholomew's  Hospital,  London.  Lithographic  Plates  and  other  Illustrations. 

Cloth,  $4.50 

CULLINGWORTH.  A  Manual  of  Nursing,  Medical  and  Surgical.  By  CHARLES 
J.  CULLINGWORTH,  M.D.,  Physician  to  St.  Mary's  Hospital,  Manchester,  England. 
Second  Edition.  With  18  Illustrations.  I2mo.  Cloth,  $1.00 

A  Manual  for  Monthly  Nurses.    32mo.  Cloth,  .50 

CURLING.    On  the  Diseases  of  the  Testis,  Spermatic  Cord  and  Scrotum.    By 

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Cloth,  $5.50 

DAGUENET'S  Ophthalmoscopy.  A  Manual  for  the  Use  of  Students.  By  Dr. 
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Illustrated.  I2mo.  Cloth,  $1.50 

DALBY.  The  Ear.  The  Diseases  and  Injuries  of  the  Ear.  By  W.  B.  DALBV,  M.D., 
Surgeon  and  Lecturer  on  Aural  Surgery,  St.  George's  Hospital.  With  Illustra- 
tions. i2mo.  Cloth,  $1.50 

DAY.  Diseases  of  Children.  A  Practical  and  Systematic  Treatise  for  Practitioners 
and  Students.  By  Wm.  H.  DAY,  M.D.  Second  Edition.  Rewritten  and  very 
much  Enlarged.  8yo.  752  pp.  Price  reduced.  Cloth,  $3.00;  Sheep,  $4.00 

On  Headaches.     The  Nature,  Causes  and  Treatment  of  Headaches.     Fourth 
Edition.     Illustrated.     8vo.  Paper,  .75;  Cloth,  $1.25 

DILLNBERGER.  On  Women  and  Children.  A  Handbook  of  the  Treatment 
of  the  Diseases  Peculiar  to  Women  and  Children.  By  Dr.  EMIL  DILLNBERGER. 
I2mo.  Cloth,  $1.50 

DOMVILLE.  Manual  for  Nurses  and  others  engaged  in  attending  to  the  sick.  By 
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Cloth,  .75 

DULLES.  What  to  Do  First,  In  Accidents  and  Poisoning.  By  C.  W.  DULLES,  M.D. 
Second  Edition,  Enlarged,  with  new  Illustrations.  Cloth,  .75 

DUNCAN,  On  Sterility  in  Women.  By  J.  MATHEWS  DUNCAN,  M.D.,  LL.D.,  Obstetric 
Physician  to  St.  Bartholomew's  Hospital,  etc.  Octavo.  Cloth,  $2.00 

DURKEE,  On  Gonorrhoea  and  Syphilis.  By  SILAS  DURKEE,  M.D.  Sixth  Edition. 
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ELLIS.  What  Every  Mother  Should  Know.  By  EDWARD  ELLIS,  M.D.,  late 
Physician  to  the  Victoria  Hospital  for  Children,  London.  I2mo.  Cloth,  .75 

EDWARDS.  Blight's  Disease.  How  a  Person  Affected  with  Bright's  Disease 
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Malaria :  What  It  Means ;  How  to  Escape  It ;  Its  Symptoms ;  When  and 
Where  to  Look  For  It.  Price  Reduced.  Cloth,  .50 

Vaccination  and  Smallpox.  Showing  the  Reasons  in  favor  of  Vaccination, 
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FAGGE.  The  Principles  and  Practice  of  Medicine.  By  C.  HILTON  FAGGE,  M.D., 
F.R.C.P.,  F  R.M.C.S.,  Examiner  in  Medicine,  University  of  London  ;  Physician  to, 
and  Lecturer  on  Pathology  in,  Guy's  Hospital ;  Senior  Physician  to  Evelina  Hos- 
pital for  Sick  Children,  etc.  Arranged  for  the  press  by  PHILIP  H.  PYE-SMITH,  • 
M.D.,  Lect.  on  Medicine  in  Guy's  Hospital.  Including  a  section  on  Cutaneous 
Affections,  by  the  Editor;  Chapter  on  Cardiac  Diseases,  by  SAMUEL  WILKES,  M.D., 
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8vo.  Cloth,  $10.00;  Leather,  $12.00  ;  Russia,  $14.00. 

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tions. By  SAMUEL  FENWICK,  M.D.,  i2mo.  Cloth,  $1.25 

FIELD.  Evacuant  Medication — Cathartics  and  Emetics.  By  HENRY  M.  FIELD, 
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ber Gynaecological  Society  of  Boston,  etc.  I2mo.  250  pp.  In  Press. 

FLAGG'S  Plastics  and  Plastic  Filling;  As  Pertaining  to  the  Filling  of  all  Cavities 
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Cavities  in  Teeth  of  all  Grades  of  Structure.  By  J.  FOSTER  FLAGG,  D.D.S.,  Pro- 
fessor in  the  Philadelphia  Dental  College.  8vo.  Second  Ed.  Cloth,  $4.00 

FLOWER'S  Diagrams  of  the  Nerves  of  the  Human  Body.  Exhibiting  their 
Origin,  Divisions  and  Connections,  with  their  Distribution  to  the  various  Regions 
of  the  Cutaneous  Surface,  and  to  all  the  Muscles.  By  WILLIAM  H.  FLOWER, 
F.R.C.S.,  F.R.S.,  Hunterian  Professor  of  Comparative  Anatomy,  and  Conservator 
of  the  Museum  of  the  Royal  College  of  Surgeons.  Third  Edition,  thoroughly 
revised.  With  six  Large  Folio  Maps  or  Diagrams.  4to.  Cloth,  $3.50 

FLUCKIGER.  The  Cinchona  Barks  Pharmacognostically  Considered.  By 
Professor  FRIEDRICH  FLOCKIGER,  of  Strasburg.  Translated  by  FREDERICK  B. 
POWER,  PH.D.,  Professor  of  Materia  Medica  and  Pharmacy,  University  of  Wis- 
consin. With  8  Lithographic  Plates.  Royal  octavo.  Cloth,  $1.50 

FOTHERGILL.  On  the  Heart  and  Its  Diseases.  With  Their  Treatment.  In- 
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Royal  College  of  Physicians  of  London.  2d  Ed.  Re-written.  8vo.  Cloth,  $3.50 

FOX.  Water,  Air  and  Food.  Sanitary  Examinations  of  Water,  Air  and  Food. 
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Cloth,  $4.00 

FOX   AND    GOULD.     Compend  on  Diseases  of  the  Eye  and  Refraction, 

including  Treatment  and  Surgery.  By  L.  WEBSTER  Fox,  M.D.,  Chief  Clinical 
Assistant,  Ophthalmological  Department,  Jefferson  Medical  College  Hospital ; 
Ophthalmic  Surgeon,  Germantown  Hospital,  Philadelphia  ;  late  Clinical  Assistant 
at  Moorfields,  London,  England,  etc.,  and  GEO.  M.  GOULD,  A.B.  60  Illustrations. 
Being  No.  8,  Quiz  Compend  Series.  Cloth,  $1.00 

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FRANKLAND'S  Water  Analysis.  For  Sanitary  Purposes,  with  Hints  for  the  In- 
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How  to  Teach  Chemistry.     Six  Lessons  to  Science  Teachers.     Edited  by 
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GALABIN'S  Midwifery.  A  Manual  for  Students  and  Practitioners.  By  A.  LEWIS 
GALABIN,  M.D.,  F.R.C.P.,  Obstetric  Physician  to  Guy's  Hospital,  London,  and 
Professor  of  Midwifery  in  the  same  institution.  227  Illustrations. 

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GAMGEE.  Wourds  and  Fractures.  The  Treatment  of  Wounds  and  Fractures. 
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Hospital,  Birmingham.  34  Engravings.  Second  Edition.  8vo.  Cloth,  $3.50 


MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  11 

GARDNER'S  TECHNOLOGICAL  SERIES.   The  Brewer,  Distiller  and  Wine 

Manufacturer.     A  Handbook  for  all  Interested  in  the  Manufacture  and  Trade 
of  Alcohol  and  Its  Compounds.     Edited  by  JOHN  GARDNER,  F.c.s.     Illustrated. 

Cloth,  $1.75 

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Oils  and  Varnishes.    Edited  by  JAMES  CAMERON,  F.I.C.    Illustrated.     $2.- 50 

GIBBES'S  Practical  Histology  and  Pathology.  By  HENEAGE  GIBBES,  M.B.  i2mo. 
Third  Edition.  Cloth,  $1.75 

GILL.  Indigestion:  What  it  is  ;  What  it  Leads  to  ;  and  a  New  Method  of  Treating 
it.  By  JOHN  BEADNELL  GILL,  M.D.  Third  Edition.  i2mo.  Cloth,  $1.25 

GILLIAM'S  Pathology.  The  Essentials  of  Pathology ;  a  Handbook  for  Students. 
By  D.  TOD  GILLIAM,  M.D.,  Professor  of  Physiology,  Starling  Medical  College, 
Columbus,  O.  With  47  Illustrations.  I2mo.  Cloth,  $2.00 

GLISAN'S  Modern  Midwifery.  A  Text-book.  By  RODNEY  GLISAN,  M.D.,  Emeritus 
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University,  Portland,  Oregon.  129  Illus.  8vo.  Cloth,  $4.00  ;  Leather,  $5.00 

GODLEE'S  Atlas  of  Anatomy.     Illustrating  most  of  the  Ordinary  Dissections  and 
many  not  usually  practiced  by  the  Student.     With  References  and  an  Explana- 
tory Text,  and  48  Colored  Plates.     By  RICKMAN  JOHN  GODLEE,  M.D.,  F.R.C.S. 
A  large  Folio  Volume,  with  References,  and  a  Separate  Volume  of  Letter-press. 
The  two  Volumes,  Atlas  and  Letter-press,  Cloth,  $20.00 

GOODHART  and  STARR'S  Diseases  of  Children.  The  Student's  Guide  to  the 
Diseases  of  Children.  By  J.  F.  GOODHART,  M.D.,  F.R.C.P.,  Physician  to  Evelina 
Hospital  for  Children,  Demonstrator  of  Morbid  Anatomy  at  Guy's  Hospital. 
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eases of  Children,  in  the  University  of  Pennsylvania.  Cloth,  $3.00;  Leather,  $3.50 

GORGAS'S  Dental  Medicine.  A  Manual  of  Materia  Medica  and  Therapeutics. 
By  FERDINAND  J.  S.  GORGAS,  M.D.,  D.D.S.,  Professor  of  the  Principles  of  Dental 
Science,  Dental  Surgery  and  Dental  Mechanism,  in  the  Dental  Department  of 
the  University  of  Maryland.  Second  Edition.  Enlarged.  8vo.  Cloth,  $3.25 

GOWERS,  Spinal  Cord.     Diagnosis  of  Diseases  of  the  Spinal  Cord.    With  Colored 

Plates  and  Engravings.    Fourth  Edition.    Enlarged.    By  WILLIAM  R.  GOWERS, 

M.D.,  Ass't  Prof.  Clinical  Medicine,  University  College,  London.  In  Press. 

Ophthalmoscopy.      A    Manual    and   Atlas    of    Ophthalmoscopy.      With    16 

Colored  Autotype  and  Lithographic  Plates  and  26  Wood  Cuts,  comprising 

112  Original  Illustrations  of  the  Changes  in  the  Eye  in  Diseases  of  the 

Brain,  Kidneys,  etc.     8vo.  Cloth,  $6.00 

Epilepsy  and  other  Chronic  Convulsive  Diseases :  Their  Causes,  Symptoms, 

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Diagnosis  of  Diseases  of  the  Brain.    8vo.   Second  Ed.   Illustrated.    In  Press. 

Manual  of  Diseases  of  the  Nervous  System.  Vol.  I,  Spinal  Cord  and 
Nerves.  With  171  phototype  Plates,  comprising  350  illustrations  of  Symp- 
toms and  Morbid  Anatomy.  8vo.  Cloth,  $4.50 

GROSS'S  Biography  of  John  Hunter.  John  Hunter  and  His  Pupils.  By  S.  D. 
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With  a  Portrait.  8vo.  Paper,  .75;  Cloth,  $1.25 

GREENHOW.  Chronic  Bronchitis,  especially  as  connected  with  Gout,  Emphy- 
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Paper,  .75;  Cloth,  #1.25 

Addison's  Disease.  Illustrated  by  Plates  and  Reports  of  Cases.  By  E. 
HEADLAM  GREENHOW,  M.D.  8vo.  Cloth,  $3.00 

HABERSHON.  On  Some  Diseases  of  the  Liver.  By  S.  O.  HABERSHON,  M.D., 
F.R.C.P.,  late  Senior  Physician  to  Guy's  Hospital.  A  New  Edition.  Cloth,  $1.50 

HALE.  On  the  Management  of  Children  in  Health  and  Disease.  A  Book  for 
Mothers.  By  AMIE  M.  HALE,  M.D.  New  Enlarged  Edition.  i2mo.  Cloth,  .75 


12  P.  BLAKISTON,  SON  6-  CO.'S 

HANDY'S  Text-Book  of  Anatomy  and  Guide  to  Dissections.  For  the  Use  of 
Students.  By  W.  R.  HANDY,  M.D.  312  Illustrations.  8vo.  Cloth,  $3.00 

HARE.  Tobacco,  Its  Physiological  and  Pathological  Effects.  8vo.  Illustrated. 
The  Fiske  Fund  Prize  Dissertation  for  1885.  Paper  Covers,  .50 

HARLAN.  Eyesight  and  How  to  Care  for  It.  By  GEORGE  C.  HARLAN,  M.D., 
Prof,  of  Diseases  of  the  Eye,  Philadelphia  Poly  clinic.  Illustrated.  Cloth,  .50 

HARLEY.  Diseases  of  the  Liver,  With  or  Without  Jaundice.  Diagnosis  and 
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Illustrations.  8vo.  Price  reduced.  Cloth,  $3.00  ;  Leather,  $4.00 

HARRIS'S  Principles  and  Practice  of  Dentistry.  Including  Anatomy,  Physi- 
ology, Pathology,  Therapeutics,  Dental  Surgery  and  Mechanism.  By  CHAPIN  A. 
HARRIS,  M.D.,  D.D.S.,  late  President  of  the  Baltimore  Dental  College,-  author  of 
"  Dictionary  of  Medical  Terminology  and  Dental  Surgery."  Eleventh  Edition. 
Revised  and  Edited  by  FERDINAND  J.  S.  GORGAS,  A.M.,  M.D.,  D.D.S.,  author  of 
"Dental  Medicine;"  Professor  of  the  Principles  of  Dental  Science,  Dental 
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Plates  and  744  Illustrations.  994  pages.  8vo.  Cloth,  $6.50;  Leather,  $7.50 

Medical  and  Dental  Dictionary.  A  Dictionary  of  Medical  Terminology, 
Dental  Surgery,  and  the  Collateral  Sciences.  Fourth  Edition,  carefully 
Revised  and  Enlarged.  By  FERDINAND  J.  S.  GORGAS,  M.D.,  D.D.S.,  Prof,  of 
Dental  Surgery  in  the  Baltimore  College.  8vo.  Cloth,  $6.50  ;  Leather,  $7.50 

HARTRIDGE.  Refraction.  The  Refraction  of  the  Eye.  A  Manual  for  Students. 
By  GUSTAVUS  HARTRIDGE,  F.R.C.S.,  Consulting  Ophthalmic  Surgeon  to  St.  Bar- 
tholomew's Hospital ;  Ass't  Surgeon  to  the  Royal  Westminster  Ophthalmic  Hos- 
pital, etc.  94  Illustrations  and  Test  Types.  Second  Edition.  Cloth,  $2.00 

HARTSHORNE.  Our  Homes.  Their  Situation,  Construction,  Drainage,  etc.  By 
HENRY  HARTSHORNE,  M.D.  Illustrated.  Cloth,  .50 

HEADLAND'S  Action  of  Medicines.  On  the  Action  of  Medicines  in  the  System. 
By  F.  W.  HEADLAND,  M.D.  Ninth  American  Edition.  8vo.  Cloth,  $3.00 

HEATH'S  Operative  Surgery.  A  Course  of  Operative  Surgery,  consisting  of  a 
Series  of  Plates,  Drawn  from  Nature  by  M.  Leveille,  of  Paris.  With  Descriptive 
Text  of  Each  Operation.  By  CHRISTOPHER  HEATH,  F.R.C.S.,  Holme  Professor 
of  Clinical  Surgery  in  University  College,  London.  Quarto.  Second  Edition. 
Revised.  Sold  by  Subscription.  Cloth,  $12.00 

Minor  Surgery  and  Bandaging.  Eighth  Edition.  Revised  and  Enlarged. 
With  142  Illustrations.  I2mo.  Cloth,  $2.00 

Practical  Anatomy.  A  Manual  of  Dissections.  Sixth  London  Edition.  24 
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Injuries  and  Diseases  of  the  Jaws.    Third  Edition.    Revised,  with  over 

150  Illustrations.     8vo.  Cloth,  $4.50 

Surgical  Diagnosis.  Cloth,  $1.25 

HIGGINS'  Ophthalmic  Practice.  A  Handbook  for  Students  and  Practitioners. 
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pital. Second  Edition.  i6mo.  Cloth,  .50 

HILLIER.  Diseases  of  Children.  A  Clinical  Treatise.  By  THOMAS  HILLIER, 
M.D.  8vo.  Paper,  .75;  Cloth,  $1.25 

HILL  AND  COOPER.  Venereal  Diseases.  The  Student's  Manual  of  Venereal 
Diseases,  being  a  concise  description  of  those  Affections  and  their  Treatment. 
By  BERKELEY  HILL,  M.D.,  Professor  of  Clinical  Surgery,  University  College,  and 
ARTHUR  COOPER,  M.D.,  Late  House  Surgeon  to  the  Lock  Hospital.  London. 
4th  Edition.  I2mo.  Cloth,  $1.00 

HODGE'S  Note-book  for  Cases  of  Ovarian  Tumors.  By  H.  LENOX  HODGE,  M.D. 
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MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS,  13 

HOLDEN'S  Anatomy.  A  Manual  of  the  Dissections  of  the  Human  Body.  By 
LUTHER  HOLDEN,  F.R.C.S.  Fifth  Edition.  Carefully  Revised  and  Enlarged. 
Specially  concerning  the  Anatomy  of  the  Nervous  System,  Organs  of  Special 
Sense,  etc.  By  JOHN  LANGTON,  F.R.C.S.,  Surgeon  to,  and  Lecturer  on  Anatomy 
at,  St.  Bartholomew's  Hospital.  208  Illustrations.  8vo. 

Oilcloth  Covers,  for  the  Dissecting  Room,  $4.50 ;  Cloth,  $5.00  ;  Leather,  $6.00 

Landmarks.  Medical  and  Surgical.  Third  London  Edition.  Revised 
and  Enlarged.  New  Edition  Preparing. 

Human  Osteology.  Comprising  a  Description  of  the  Bones,  with  Colored 
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PART  I — Treats  of  Light,  Heat  and  Electricity,  which  are  described  at  some  length,  and  explanations  made 
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Practical  and  Analytical  Chemistry. 

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BY  HENRY   TRIMBLE,  Ph.G., 

Professor  of  Analytical  Chemistry  in  the  Philadelphia  College  of  Pharmacy. 

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Detection  of  Bases  and  Acids.  Section  IV — Some  of  the  Reactions  and  Tests  of  Purity  of  the  more  import- 
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Section  II — Volumetric  Estimation.  Ihere  are  also  a  number  of  useful  Tables. 

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FIFTH  EDITION,  REVISED  AND  ENLARGED.    208  ILLUSTRATIONS. 
A  MANUAL  OF  THE  DISSECTIONS  OF  THE  HUMAN  BODY. 

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DIAGRAM    OF   AXILLA. 
(from  Holdeifs  Anatomy.) 


AXILLARY  ARTERY. 
BKACHIAL  ARTERY. 
THORACICA  HUMERARIA  ARTERY. 
SUPERIOR  THORACIC  ARTERY. 
SUBSCAPULAR  ARTERY. 
DORSALIS  SCAPULA  ARTERY. 
POSTERIOR  CIRCUMFLEX  ARTERY. 
SUPERIOR  PROPUNDA  ARTERY. 
POSTERIOR  THORACIC  NERVE. 
LONG  SUESCAPULAR   NERVK. 
MEDIAN  NKRVK. 
CEPHALIC  VEIN. 
MUSCULO-CUTANBOUS  NSRVB. 
TEHBS  MAJOR. 


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striking  and  suggestive,  giving  more  at  a  glance  than  pages  of  text  description.  All  this  is  known  to  those  who 
are  already  acquainted  with  this  admirable  work  ;  but  it  is  simple  justice  to  its  value,  as  a  work  for  careful  study 
and  reference,  that  these  points  be  emphasized  to  such  as  are  commencing  their  studies.  The  text  matches  the 
illustrations  \\\  directness  of  practical  application  and  clearness  of  detail." — JVeiv  York  Mtdical  Record,  April 
iSth,  rSSs.  BY  THE  SAME  AUTHOK 

HUMAN  OSTEOLOGY.     Comprising  a  description  of  the  Bones,  with  Colored  Delinea 
tions  of  the  Attachments  of  the  Muscles.     The  General  and  Microscopical   Structure  of 
Bone  and  its  Development.     Carefully  Revised.     By  the  Author  and  A.  DORAN,  F.R.C.S., 
with  Lithographic  Plates  and  Numerous  Illustrations.     Sixth  Edition.     8vo.     Cloth,  $6.00 

Sixth  London  Edi- 
Cloth,  $5.00 


HEATH'S  PRACTICAL  ANATOMY.     A  Manual  of  Dissections, 
tion.     24  Colored  Plates,  and  nearly  300  other  Illustrations. 


P.  BLAKISTON,  SON  &  CO.,  1012  Walnut  St.,  Philadelphia. 


NEW  SURGICAL  WORKS  JUST  PUBLISHED. 


Amputations  of  the  Extremities  and  Their  Complications.  By  B.  A.  WATSON,  A.M., 
M.D.,  Surgeon  to  the  Jersey  City  Charity  Hospital,  to  St.  Francis'  and  to  Christ's 
Hospital,  at  Jersey  City,  N.  J. ;  Fellow  of  the  American  Surgical  Association ; 
Member  of  the  New  York  Pathological  Society,  etc.  Two  full-page  Colored 
Plates,  and  two  hundred  and  fifty-five  Wood  Engravings.  Octavo.  762  -f  xix 
Pages.  Handsomely  bound  in  Cloth,  $5.50. 


SPECIMEN   OF   ILLUSTRATIONS  IN  WATSON*S   AMPUTATIONS. 

"  This  volume  is  an  encyclopaedic  monograph,  containing  the  important  facts,  theories  and  arguments  relating 
to  amputations  of  the  extremities,  and  their  complications.  The  author's  aim  has  been  to  collect  facts  on  this 
subject  from  English,  French,  German  and  American  literature.  He  does  not  lay  claim  to  originality,  but,  of 
course,  introduces,  in  their  proper  places,  those  observations  which  his  own  experience  has  led  him  to  make  on 
the  general  subject.  Under  the  division  of  '  Complications,'  the  general  subject  of  the  treatment  of  wounds  is 
discussed,  with  an  outline  of  the  present  views  on  germs  and  germicides,  for,  in  the  words  of  the  preface,  the 
complications  of  amputation  wounds  are  essentially  the  same  as  those  which  pertain  to  any  solution  of  continuity 
involving  the  various  tissues  of  the  body.  A  great  service  has  been  done  the  profession  by  the  insertion  of  a 
translation  of  Gaupot's  and  Spellmann's  writings  on  artificial  limbs.  This  is  the  fullest  exposition  of  the  subject 
we  have  yet  seen  in  an  American  text-book.  Too  much  praise  cannot  be  given  to  the  typographical  appearance 
of  the  work.  The  illustrations  are  marvels  of  clearness,  and  do,  what  is  not  always  the  case,  elucidate  the  text." 
— Medical  Record,  New  York,  June  zoth,  iSSf. 

Pye's  Surgical  Handicraft. 

A  Manual  of  Surgical  Manipulations,  Minor  Surgery,  Bandaging,  Dressing,  etc.,  etc., 
for  the  use  of  General  Practitioners  and  Students.  With  special  chapters  on 
Aural  Surgery,  Extraction  of  Teeth,  Anaesthetics,  etc.  By  WALTER  PYE,  F.R.C.S., 
Surgeon  to  St.  Mary's  Hospital  and  the  Victoria  Hospital  for  Sick  Children  ; 
Examiner  in  Surgery  at  the  University  of  Glasgow.  208  Illustrations.  Octavo. 

Cloth,  $5.00. 

Heath's  Operative  Surgery. 

A  Course  of  Operative  Surgery,  consisting  of  a  Series  of  Colored  Plates,  each  plate 
containing  Several  Figures,  Drawn  from  Nature  by  the  Celebrated  Anatomical 
Artist,  M.  L6veille,  of  Paris,  Engraved  on  Steel  under  his  immediate  superinten- 
dence, with  Descriptive  Text  of  Each  Operation,  and  numerous  Wood  Engravings. 
By  CHRISTOPHER  HEATH,  F.R.C.S.,  Surgeon  to  University  College  Hospital,  and 
Holme  Professor  of  Clinical  Surgery  in  University  College,  London.  One  Large 
Quarto  Volume.  Second  Edition,  Revised  and  Enlarged.  Sold  by  Subscription. 
Full  information  upon  application.  Cloth,  $12.00. 

P.  BLAKISTON,  SON  &  CO.,  1012  Walnut  St.,  Philadelphia. 


Practical  Handbooks 

FOR  THE  PHYSICIAN  AND  MEDICAL  STUDENT. 


VAN  HARLINGEN  ON  SKIN  DISEASES.  A  Handbook  of  the  Diag- 
nosis and  Treatment  of  Skin  Diseases.  By  ARTHUR  VAN  HARLINGEN,  M.D., 
Professor  of  Diseases  of  the  Skin  in  the  Philadelphia  Polyclinic;  Consulting 
Physician  to  the  Philadelphia  Dispensary  for  Skin  Diseases,  and  Dermatologist 
to  the  Howard  Hospital.  With  colored  plates  representing  the  appearance  of 
various  lesions.  I2mo.  Cloth,  $1.75 

***  This  is  a  complete  epitome  of  skin  diseases,  arranged  in  alphabetical  order, 
giving  the  diagnosis  and  treatment  in  a  concise,  practical  way.  Many  prescriptions 
are  given  that  have  never  been  published  in  any  text-book,  and  an  article  incorporated 
on  Diet.  The  plates  do  not  represent  one  or  two  cases,  but  are  composed  of  a  num- 
ber of  figures,  accurately  colored,  showing  the  appearance  of  various  lesions,  and 
will  be  found  to  give  great  aid  in  diagnosing. 

'"  This  new  handbook  is  essentially  a  small  encyclopaedia.  *  *  *  Contains  a  very  complete  summary  of  the 
present  state  of  Dermatology.  *  *  *  We  heartily  commend  it  for  its  brevity,  clearness  and  evidently  careful 
preparation." — Philadelphia  Medical  Times. 

"  The  author  shows  a  proper  appreciation  of  the  wants  of  the  general  practitioner." — New  York  Medical 
Record. 

"  It  is  concisely  and  intelligently  written,  and  contains  many  of  the  best  formulas  in  use  for  the  various  forms 
of  Skin  Disease/'— New  York  Medical  Times. 

"  This  is  an  excellent  little  book,  in  which,  for  ease  of  reference,  the  more  common  diseases  of  the  skin  arc 
arranged  in  alphabetical  order,  while  many  good  prescriptions  are  given,  together  with  clear  and  sensible  direc- 
tions as  to  their  proper  application." — Boston  Medical  and  Surgical  Journal. 

"  It  is  just  the  kind  of  book  that  the  general  practitioner  will  find  most  convenient  for  reference,  and  we  feel 
confident  that  it  will  be  appreciated."— Southern  Practitioner. 

EINDFLEISCH'S  PATHOLOGY.  The  Elements  of  Pathology.  By  PROF. 
EDWARD  RINDFLEISCH,  University  of  Wurzburg.  Authorized  translation  from 
the  first  German  edition,  by  WM.  H.  MERCUR,  M.D.  (Univ.  of  Pa.)  Revised  by 
JAMES  TYSON,  M.D.,  Professor  of  Pathology  and  Morbid  Anatomy  in  the  Univer- 
sity of  Pennsylvania.  I2mo.  Cloth,  $2.00 

Prof.  Tyson,  in  his  Preface  to  the  American  edition,  says  : — "A  high  appreciation  of  Prof.  Rindfleisch's 
work  on  Pathological  Histology,  caused  me  to  make  careful  examination  of  these  '  Elements '  immediately  after 
their  publication  in  the  original.  From  such  an  examination  I  became  satisfied  that  the  book  would  fill  a  niche 
in  the  wants  of  the  student,  as  well  as  of  others  who  may  desire  to  familiarize  themselves  with  general  patho- 
logical processes,  viewed  from  the  most  modern  standpoint." 

BEUEN'S  PHYSICAL  DIAGNOSIS.  Second  Edition.  A  Pocket-book 
of  Physical  Diagnosis  of  the  Heart  and  Lungs ;  for  the  Student  and  Physician. 
By  EDWARD  T.  BRUEN,  Demonstrator  of  Clinical  Medicine  in  the  University  of 
Pennsylvania ;  Lecturer  on  Pathology  in  the  Women's  Medical  College  of  Phila- 
delphia ;  2d  Edition,  revised,  with  new  original  illustrations.  I2mo.  Cloth,  $1.50 

"  We  consider  the  description  of  the  manner  and  rules  governing  the  art  of  percussion  well  given.  The  sub- 
ject is  always  a  difficult  one  for  beginners,  and  requires  to  be  well  handled  in  order  to  be  properly  understood." 
— American  Journal  of  Medical  Sciences. 

WOAKES  ON  CATARRH  AND  DISEASES  OF  THE  NOSE  CAUS- 
ING DEAFNESS.  By  EDWARD  WOAKES,  M.D.,  Senior  Aural  Surgeon  to 
the  Lpndon  Hospital  for  Diseases  of  the  Throat  and  Chest.  29  Illustrations. 
I2mo.  Cloth,  $1.50 

"  Out  of  the  large  number  of  .special  works  on  catarrh,  there  is  none  for  which  we  have  such  an  unqualified 
good  opinion.  *  *  *  The  subject  is  clearly  presented.  *  *  •  The  line  of  treatment  suggested  is  rational." 
— North  Carolina  Medical  Journal. 

P.  BLAKISTON,  SON  &  CO.,  1012  Walnut  St.,  Philadelphia. 


•PRACTICAL  HANDBOOKS— Continued. 

VON  ARLT.  DISEASES  OF  THE  EYE.  Including  those  of  the  Con- 
junctiva, Cornea,  Sclerotic,  and  of  the  Iris  and  Ciliary  Body.  By  DR.  FERDI- 
NAND RITTER  VON  ARLT,  Professor  of  Ophthalmology  in  Vienna.  Translated 
by  LYMAN  WARE,  M.D.,  Surgeon  to  the  Illinois  Charitable  Eye  and  Ear  Infirmary ; 
Ophthalmic  Surgeon  to  the  Presbyterian  Hospital,  and  to  the  Protestant  Orphan 
Asylum,  Chicago.  Illustrated.  8vo.  325  pages.  Cloth,  $2.50 

"  His  style  is  condensed  but  clear,  and  his  pages  contain  a  vast  amount  of  information,  couched  in  such  lan- 
guage that  it  will  be  equally  instructive  to  the  general  practitioner  and  the  specialist." — Philadelphia  Medical 
and  Surgical  Reporter,  May  jot  A,  iHSf- 

TYSON  ON  THE  URINE.  A  Practical  Guide  to  the  Examination  of  Urine. 
For  the  Use  of  Physicians  and  Students.  With  Colored  Lithographic  Plates  and 
Numerous  Illustrations  Engraved  on  Wood.  Fourth  Edition.  I2mo.  Cloth,  $1.50 

"  The  practical  man  will  find  in  this  little  book  all  that  is  absolutely  necessary  for  him  to  know,  in  order  to 
utilize  fully  the  data  supplied  by  the  urine." — Chicago  Medical  Journal. 

GILT  JAM'S  ESSENTIALS  OF  PATHOLOGY.  The  Essentials  of  Path- 
ology. By  D.  TOD  GILLIAM,  M.D.,  Professor  of  Physiology,  Starling  Medical 
College,  Columbus,  Ohio.  With  47  wood  engravings.  I2mo.  Cloth,  $2.00 

"  The  general  practitioner  will  find  in  this  little  12010  a  convenient  compendium  of  the  current  pathology  of 
the  day." — Chicago  Medical  Journal  and  Examiner. 

THE  PRACTICAL  SERIES. 

A  NEW  VOLUME  JUST  READY. 

*#*  The  volumes  of  this  series  written  by  well  known  physicians  and  surgeons,  ol 
large  private  and  hospital  experience,  recognized  authorities  on  the  subjects  of  which 
they  treat,  will  embrace  the  various  branches  of  medicine  and  surgery.  They  are  of 
a  thoroughly  practical  character,  calculated  to  meet  the  requirements  of  the  practi- 
tioner, and  will  present  the  most  recent  methods  and  information  in  a  compact  shape 
and  at  a  low  price.  Bound  uniformly,  in  a  handsome  and  distinctive  cloth  binding. 

DISEASES  OF  THE  KIDNEYS,  AND  URINARY  DERANGE- 
MENTS. By  C.  H.  RALFE,  M.A.,  M.D.,  F.R.C.P.,  Assistant  Physician  to  the 
London  Hospital ;  late  Senior  Physician  to  the  Seamen's  Hospital,  Greenwich. 
12010.  With  Illustrations.  572  pages.  Just  Ready.  Cloth,  $2.75 

"  The  object  of  this  rolume  is  to  present  the  student  and  practitioner  with  a  clear,  concise  and  systematic 

authorities.     Througho-., _,....„.   .„,  „.„ 

diagnosis  of  the  various  renal  and  urinary  dis 
The  Preface. 

BODILY  DEFORMITIES  AND  THEIR  TREATMENT.  A  Handbook 
of  Practical  Orthopaedics.  By  H.  A.  REEVES,  F.R.C.S.,  Senior  Assistant  Surgeon 
and  Teacher  of  Practical  Surgery  at  the  London  Hospital;  Surgeon  to  the  Royal 
Orthopaedic  Hospital,  etc.  I2mo.  228  Illustrations.  460  pages.  Cloth,  $2.25 

"  From  what  we  have  already  said,  it  will  be  seen  that  Mr.  Reeves  has  given  us  a  trustworthy  guide  for  the 
treatment  of  a  very  extended  class  of  cases.  *  *  *  If  the  other  volumes  of  the  Practical  Series  are  as  good 
as  this,  we  shall  be  agreeably  disappointed." — American  Journal  of  Medical  Sciences,  April,  J88j. 

"  The  utility  of  the  work  now  before  us  cannot  be  better  recommended  to  the  appreciation  of  the  professional 
reading  public,  than  by  recalling  that  it  is  the  first  of  its  kind,  dealing  with  orthopaedics  from  a  modern  stand- 
point."— Hospital  Gazette  and  Students'  Journal. 

DENTAL  SURGERY  FOR  GENERAL  PRACTITIONERS  AND 
STUDENTS  IN  MEDICINE.  By  ASHLEY  W.  BARRETT,  M.D.,  M.R.C.S. 
ENG.,  Surgeon-Dentist  to,  and  Lecturer  on  Dental  Surgery  and  Pathology  in  the 
Medical  School  of,  London  Hospital.  I2mo.  Illustrated.  Cloth,  jSi.oo 

"  Replete  with  an  abundance  of  practical  information  of  unquestionable  utility." — Hospital  Gazette  and 
Students'  Journal. 

P.  BLAKISTON,  SON  &  CO.,  1012  Walnut  St.,  Philadelphia. 


A      T^T  o      'OO*  r    i%  /r  i 

A  New  Series  or  Manuals 

FOR 

^    ;   MEDICAL  STUDENTS.    ^ 

UNIFORM    IN    SIZE,    PRICE    AND    BINDING. 
Price  of  Each  Book,  Cloth,  $3.0O ;  Leather,  $3.50. 

MIDWIFERY.  By  ALFRED  LEWIS  GALABIN,  M.A.,  M.D.,  Obstetric  Physi- 
cian to,  and  Lecturer  on  Midwifery  and  the  Diseases  of  Women  at,  Guy's 
Hospital,  London,  etc.  227  fine  Engravings.  753  pages. 

PHYSIOLOGY.  By  GERALD  F.  YEO,  M.D.,  F.R.C.S.,  Professor  of  Physi- 
ology in  King's  College,  London.  Second  Edition,  revised.  750  pages. 
301  carefully  printed  Illustrations. 

MATERIA  MEDICA,  PHARMACY  AND  THERAPEUTICS, 
including  the  Physiological  Action  of  Drugs,  Special  Therapeutics,  Offi- 
cial and  Extemporaneous  Pharmacy,  with  numerous  Tables,  Formulae, 
Notes  on  Temperature,  Clinical  Thermometer,  Poisons,  Urinary  Examin- 
ations, and  Patent  Medicines.  By  SAM'L  O.  L.  POTTER,  M.A.,  M.D., 
Professor  of  Practice  of  Medicine,  Cooper  College,  San  Francisco,  late 
Surgeon  U.  S.  Army.  830  pages. 

CHILDREN.  By  J.  F.  GOODHART,  M.D.,  Physician  to  the  Evelina  Hospi- 
tal for  Children  ;  Assistant  Physician,  Guy's  Hospital,  London.  American 
Edition.  Revised  and  Edited  by  Louis  STARR,  M.D.  ,  Clinical  Professor 
of  Diseases  of  Children  in  the  Hospital  of  the  University  of  Pennsylvania ; 
Physician  to  the  Children's  Hospital,  Philadelphia.  50  Formulae,  and 
Directions  for  preparing  Artificial  Human  Milk,  for  the  Artificial  Diges- 
tion of  Milk,  etc.  738  pages. 

PRACTICAL  THERAPEUTICS,  with  an  Index  of  Diseases.  By  ED. 
JOHN  WARING,  M.D.,  F.R.C.P.  Fourth  Edition.  Rewritten  and  Revised. 
Edited  by  DUDLEY  W.  BUXTON,  Assistant  to  the  Professor  of  Medicine, 
University  College  Hospital,  London.  666  pages. 

MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY.  By  JOHN 
J.  REESE,  M.D.,  Professor  of  Medical  Jurisprudence  and  Toxicology, 
University  of  Pennsylvania,  etc.  606  pages. 

ORGANIC  CHEMISTRY.  By  Prof.  VICTOR  VON  RICHTER,  University 
of  Breslau.  Translated  from  Fourth  German  Edition  by  EDGAR  F. 
SMITH,  M.A.,  PH.D.,  Professor  of  Chemistry,  Wittenberg  College,  Spring- 
field, O.,  formerly  in  the  Laboratories  of  the  University  of  Pennsylvania, 
etc.  Illustrated.  710  pages. 

DISEASES  OF  WOMEN.  By  Dr.  F.  WINCKEL,  Professor  of  Gynae- 
cology, etc.,  Royal  University  of  Munich.  The  Translation  Edited  by 
THEOPHILUS  PARVIN,  M.D.,  Professor  of  Obstetrics  and  Diseases  of  Women 
and  Children,  Jefferson  Medical  College,  Philadelphia.  117  Engravings, 
most  of  which  are  new.  674  pages. 

***  Other  Volumes  in  Preparation.     A  complete  illustrated  circular,  with 
sample  pages,  sent  free,  upon  application. 

Price  of  Each  Booh,  Cloth,  $3.OO ;  Leather,  $3.5O. 
P.  BLAKISTON,  SON  &  CO.,  1012  Walnut  Street,  Philadelphia. 


?  QUIZ-COMPENDS  ? 

A  NEW  SERIES  OF  PEACTICAL  MANUALS  FOE  THE    PHYSICIAN  AND   STUDENT. 

Compiled  in  accordance  with  the  latest  teachings  of  prominent  lecturers 
and  the  most  popular  Text-books. 

They  form  a  most  complete,  practical  and  exhaustive  set  of  manuals,  containing  information 
nowhere  else  collected  in  such  a  condensed,  practical  shape.  Thoroughly  up  to  the  times  in 
every  respect,  containing  many  new  prescriptions  and  formulae,  and  over  two  hundred  and  thirty 
illustrations,  many  of  which  have  been  drawn  and  engraved  specially  for  this  series.  The 
authors  have  had  large  experience  as  quiz-masters  and  attaches  of  colleges,  with  exceptional 
opportunities  for  noting  the  most  recent  advances  and  methods.  The  arrangement  of  the  sub- 
jects, illustrations,  types,  etc.,  are  all  of  the  most  approved  form,  and  the  size  of  the  books  is 
such  that  they  may  be  easily  carried  in  the  pocket.  They  are  constantly  being  revised,  so  as  to 
include  the  latest  and  best  teachings,  and  can  be  used  by  students  of  any  college  of  medicine, 
dentistry  or  pharmacy. 

Bound  in  Cloth,  each  $1.00.     Interleaved,  for  the  Addition  of  Notes,  $1.25. 

No.  i.  Human  Anatomy.  Fourth  Edition,  including  Visceral  Anatomy,  formerly 
published  separately.  Over  100  Illustrations.  By  SAMUEL  O.  L.  POTTER,  M. A.,  M.D., 
late  A.  A.  Surgeon  U.  S.  Army.  Professor  of  Practice,  Cooper  Med.  College,  San  Francisco. 

Nos.  2  and  3.  Practice  of  Medicine.  Second  Edition.  By  DANIEL  E.  HUGHES,  M.D., 
Demonstrator  of  Clinical  Medicine  in  Jefferson  Med.  College,  Phila.  In  two  parts. 

PART  I. — Continued,  Eruptive  and  Periodical  Fevers,  Diseases  of  the  Stomach,  Intestines,  Peritoneum, 
Biliary  Passages,  Liver,  Kidneys,  etc.  (including  Tests  for  Urine),  General  Diseases,  etc. 

PART  II. — Diseases  of  the  Respiratory  System  (including  Physical  Diagnosis),  Circulatory  System  and  Ner- 
vous System  ;  Diseases  of  the  Blood,  etc. 

***  These  little  books  can  be  regarded  as  a  full  set  of  notes  upon  the  Practice  of  Medicine,  containing  the 
Synonyms,  Definitions,  Causes,  Symptoms,  Prognosis,  Diagnosis,  Treatment,  etc.,  of  each  disease,  and  including 
a  number  of  prescriptions  hitherto  unpublished. 

No.  4.  Physiology,  including  Embryology."  Third  Edition.  By  ALBERT  P.  BRUBAKER, 
M.D.,  Prof,  of  Physiology,  Penn'a  College  of  Dental  Surgery  ;  Demonstrator  of  Physiology 
in  Jefferson  Med.  College,  Phila.  Revised,  Enlarged  and  Illustrated. 

No.  5.  Obstetrics.  Illustrated.  Third  Edition.  For  Physicians  and  Students.  By 
HENRY  G.  LANDIS,  M.D.,  Prof,  of  Obstetrics  and  Diseases  of  Women,  in  Starling  Medical 
College,  Columbus.  Revised  Edition.  New  Illustrations. 

.No.  6.  Materia  Medica,  Therapeutics  and  Prescription  Writing.  Fourth  Revised 
Edition.  With  especial  Reference  to  the  Physiological  Action  of  Drugs,  and  a  complete 
article  on  Prescription  Writing.  Based  on  the  Last  Revision  (Sixth)  of  the  U.  S.  Pharma- 
copoeia, and  including  many  unofficinal  remedies.  By  SAMUEL  O.  L.  POTTER,  M.A.,  M.D., 
late  A.  A.  Surg.  U.  S.  Army;  Prof,  of  Practice,  Cooper  Med.  College,  San  Francisco.  4th 
Edition,  with  Index. 

No.  7.  Inorganic  Chemistry.  New  Edition.  By  G.  MASON  WARD,  M.D.,  Demonstrator 
of  Chemistry  in  Jefferson  Med.  College,  Phila.  Including  Table  of  Elements  and  various 
Analytical  Tables.  New  Edition. 

No.  8.  Diseases  of  the  Eye  and  Refraction,  including  Treatment  and  Surgery.  By  L. 
WEBSTER  Fox,  M.D.,  Chief  Clinical  Assistant  Ophthalmological  Dept.,  Jefferson  Medical 
College,  etc.,  and  GEO.  M.  GOULD,  A.B.  40  Illustrations. 

No.  9.  Surgery.  Illustrated.  Third  Edition.  Including  Fractures,  Wounds,  Disloca- 
tions, Sprains,  Amputations  and  other  operations;  Inflammation,  Suppuration,  Ulcers, 
Syphilis,  Tumors,  Shock,  etc.  Diseases  of  the  Spine,  Ear,  Bladder,  Testicles,  Anus,  and 
other  Surgical  Diseases.  By  ORVILLE  HORWITZ,  A.M.,  M.D.,  Demonstrator  of  Anatomy, 
Jefferson  Medical  College.  Third  Edition.  Revised  and  Enlarged.  77  Formula;  and  91 
Illustrations. 

No.  10.  Organic  Chemistry.  Including  Medical  Chemistry,  Urine  Analysis,  and  the  Analy- 
sis of  Water  and  Food,  etc.  By  HENRY  LEFFMANN,  M.D.,  Demonstrator  of  Chemistry  in 
Jefferson  Med.  College;  Prof,  of  Chemistry  in  Penn'a  College  of  Dental  Surgery,  Phila. 

No.  ii.  Pharmacy.  Based  upon  "Remington's  Text-Book  of  Pharmacy."  By  F.  E. 
STEWART,  M.D.,  PH.G.,  Quiz-Master  at  Philadelphia  College  of  Pharmacy. 

Bound  in  Cloth,  each  $1.00.     Interleaved,  for  the  Addition  of  Notes,  $1.25. 

fi^if"  These  books  are  constantly  revised  to  keep  up  -with  the  latest  teachings  and  discoveries. 

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The  Physician's  Visiting  List 

(LINDSAY  &  BLAKISTON'S.) 
PUBLISHED  ANNUALLY;   NOW  IN  ITS  THIRTY-SIXTH  YEAR. 


CALENDAR  FOR  1887  and  1888. 

TABLE  OF  SIGNS. 

MARSHALL  HALL'S  READY  METHOD  IN 
ASPHYXIA. 

POISONS  AND  ANTIDOTES. 

A  DESCRIPTION  OF  THE  METRIC  OR 
FRENCH  DECIMAL  SYSTEM  OF  WEIGHTS 
AND  MEASURES. 

DOSE  TABLE,  rewritten  in  accordance  with  the  new 
(sixth)  Revision  of  the  U.  S.  Pharmacopoeia. 

DISINFECTANTS  AND  DISINFECTING. 

EXAMINATION  OF  URINE,  prepared  by  Dr. 
JUDSON  DALAND,  based  upon  Prof.  JAS.  TYSON'S 
"  Handbook  for  Practical  Jixantination  of  Urine." 

LIST  OF  STANDARD  REFERENCE  BOOKS. 

INCOMPATIBILITY. 

A  NEW  COMPLETE  TABLE  FOR  CALCU- 
LATING THE  PERIOD  OF  UTERO-GESTA- 
TION. 


CONTENTS. 

LIST  OF  NEW  REMEDIES.    Prepared  by  SAM'L 
O.  L.  POTTER,  M  D. 


SYLVESTER'S    METHOD    FOR    ARTIFICIAL 

RESPIRATION.     Illustrated. 
DIAGRAM  OF  THE  CHEST. 


and 


BLANK  LEAVES,  for  Visiting  List. 

"   Monthly  Memoranda. 
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others. 
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references,  etc. 

"  "  "  Accounts  asked  for. 

"  "  "   Memoranda  of  Wants. 

"  "   Obstetric  and  Vaccination  En- 

gagements. 
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"  "   Cash  Account,  etc. 

NEW  FEATURES. — A  glance  at  the  above  contents  will  show  several  new 
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character  or  general  arrangement  in  any  way. 

SIZES  AND  PRICES. 

Tucks,  pockets  and  Pencil, 


For  25  Patients  weekly. 
50 

75 

IOO 
50  "  "  2  Vols. 

loo        "  "        2  Vols. 


(Jan.  to  June ) 
.  J 


For  25  Patients  weekly. 
50 

50 


I  July  to  Dec. 
f  Jan.  to  June 
j  July  to  Dec. 

INTERLEAVED   EDITION. 

Interleaved,  tucks  and  Pencil, 


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3-OO 


2  Vols. 


j  Jan.  to  June  ) 
:•) 


;.oo 


{  July  to  Dec. 

PERPETUAL  EDITION,  without  Dates. 
be  commenced  at  any  time,  and  used  until  full, 
tents  and  arrangement  to  the  regular  edition. 

No.  1.     Containing  space  for  over  1300  names,  with  blank  page  opposite  each 

Visiting  List  page.     Bound  in  Red  Leather  cover,  with  Pocket  and  Pencil, 

No.  2.    Containing  space  for  2600  names,  with  blank  page  opposite  each 

Visiting  List  page.     Bound  like  No.  i,  with  Pocket  and  Pencil 

These  lists,  without  dates,  are  particularly  useful  to  young  physicians  unable  to 
estimate  the  number  of  patients  they  may  have  during  the  first  years  of  Practice,  and 
to  physicians  in  localities  where  epidemics  occur  frequently. 

"  For  completeness,  compactness,  and  simplicity  of  arrangement  it  is  excelled  bv  none  ;n  the  market." — Ar.  Y. 
Medical  Record. 

"  The  book  is  convenient  in  form,  not  too  bulky,  and  in  every  respect  the  very  best  Visiting  List  published. "- 
Canada  Medical  and  Surgical  Journal. 

After  all  the  trials  made,  there  are  none  superior  to  it." — Gaillard's  Medical  Journal. 

It  has  become  Standard."— Southern  Clinic. 

Regular  as  the  seasons  comes  this  old  favorite." — Michigan  Medical  News. 


Similar  in  style,  con- 


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